Certified Payroll Template - Department Of Labor And Workforce

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CERTIFIED PAYROLL
Alaska Department of Labor and Workforce
Development
Labor Standards and Safety Division
Wage and Hour Administration
Contractor Name
_____Contractor
_____SubContractor
Address
Phone
Contractor License No.
Week Ending
Contracting Agency Project #
Project Name and Location
Date Work Started
Est. Completion Date
Payroll No.
Dept. Labor Project #
Contract Amount
Date of the Month
Name, SSN, Permanent Domicile Address
Specific Work Class Code
DEDUCTIONS
Union
(NO P.O. BOX or RURAL ROUTES ACCEPTED)
Including certificate #'s for
Apprentice
Member-
Total
Gross
Electricians, Plumbers,
and Mailing Address (if different) for each
OTHER
Hourly
Painters, Powderman,
(%) if
ship?
Day of the Week
Hours
Amount
(EXPLAIN)
employee
Rate Paid
FED W/H
UNION
Asbestos Workers. Truck
Applicable
If NONE
Worked
Earned
FICA
ESD
Garnish or
TAX
DUES
Social Security numbers MUST be included
drivers include truck license
Medical
S
M
T
W
TH
F
S
put N/A
number
Insurance
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Weekly Certified Payroll Form, Pg 1 of 2 - Revised July 2013

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