Public Works Payroll Reporting Form Page 2
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1
2NOTICE TO PUBLIC ENTITY
For Privacy Considerations
Fold back along dotted line prior to copying for release to general public (private persons).
(Paper Size then 8-1/2 x 11 inches)
I,
, the undersigned, am the
(Name – print)
with the authority to act for and on behalf of
(Position in business)
, certify under penalty of perjury
(Name of business and/or contractor)
that the records or copies thereof submitted and consisting of
(Description, number of pages)
are the originals or true, full, and correct copies of the originals which depict the payroll record(s)
of the actual disbursements by way of cash, check, or whatever form to the individual or
individuals named.
Date:
Signature:
A public entity may require a stricter and/or more extensive form of certification.
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Parent category: Business