New Jersey Economic Development Authority Certified Weekly Payroll Report (Page 2 of 2) in pdf

NEW JERSEY ECONOMIC DEVELOPMENT AUTHORITY

EDA Form PW-4 (page 2)

CERTIFIED WEEKLY PAYROLL REPORT (REVISED 01/2014)

Date

( C ) FRINGE BENEFITS

EXCEPTION (CRAFT)

EXPLANATION

(Name of signatory party)

(Title)

do hereby certify:

(1) That I pay or supervise the payment of the person(s) employed by

on the

(Contractor or Subcontractor)

(Project Name)

; that during the payroll period commencing on the

day of

, 20

and ending the

, day of 20

REMARKS

all persons employed on said project have been paid the full weekly wages earned, that no rebates

have been or will be made either directly or indirectly to or on behalf of said

(Contractor or Subcontractor)

from the full weekly wages earned by any person and that no deductions have been made either directly or indirectly

from the full wages earned by any person, other than permissible deductions as defined in the New Jersey Prevailing

Wage Act, N.J.S.A. 34:11-56.25 et seq. and Regulation N.J.A.C. 12:60 et seq. and the Payment of Wages Law,

PLEASE SPECIFY THE TYPE OF BENEFIT PROVIDED AND NOTE THE TOTAL

N J S A 34:11 4 1 et seq

N.J.S.A. 34:11-4.1 et seq.

COST PER HOUR IN THE FRINGE BENEFIT BOX ON PAGE 1*

COST PER HOUR IN THE FRINGE BENEFIT BOX ON PAGE 1

1) Medical or hospital coverage

2) Dental coverage

That any payrolls otherwise under this contract required to be submitted for the above

(2)

3) Pension or Retirement

period are correct and complete; that the wage rates for laborers or mechanics contained therein are not

4) Vacation, Holidays

less than the applicable wage rates contained in any wage determination incorporated into the contract;

5) Sick days

6) Life Insurance

that the classifications set forth therein for each laborer or mechanic conform with the work performed

7) Other

Explain:

___________________

(3) That any apprentices employed in the above period are duly registered in good standing,

* TO CALCULATE THE COST PER HOUR, DIVIDE 2,000 HOURS INTO THE

in a program approved or certified by the Division of Vocational Education apprenticeship in the New

BENEFIT COST PER YEAR PER EMPLOYEE

Jersey Department of Education or by the Bureau of Apprenticeship Training in the United States

(5)

N.J.A.C. 19:30-3.5-9 and 4.4 The contractors shall submit

Department of Labor.

to the NJEDA a certified payroll record each pay period.

(4) That:

NAME AND TITLE

SIGNATURE

(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS

In addition to the basic hourly wage rates paid to each laborer or mechanic

listed in the above referenced payroll, payments of fringe benefits as listed in

the contract have been or will be made to appropriate programs for the benefit

of such employees, except as noted in Section 4 (C) below.

THE FALSIFICATION OF ANY OF THE ABOVE STATEMENT MAY SUBJECT

(b) WHERE FRINGE BENEFITS ARE PAID IN CASH

THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL

Each laborer or mechanic listed in the above referenced payroll has been paid

PROSECUTION. N.J.S.A. 34:1B-1 et seq., and P.L. 1963, c. 150 - N.J.S.A. 34:11-

as indicated on the payroll, an amount not less than the sum of the applicable

56.25 et seq. and provided by Sections 11 through 16, inclusive, of P.L. 1963, c.

basic hourly wage rate plus the amount of the required fringe benefits as listed

150 - N.J.S.A. 34:11-56.35 - 34:11-56.40

in the contract, except as noted in Section 4(C) below.

( )

New Jersey Economic Development Authority Certified Weekly Payroll Report Page 2

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