Certified Payroll Template - Alaska Department Of Labor & Workforce - 2013
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1
2CERTIFIED PAYROLL
Contractor
:
Contractor
Subcontractor
Name
Address:
Alaska Department of Labor &
Workforce Development
Labor Standards & Safety Phone
Contractor License Number
Week Ending:
Payroll No.
Contracting Agency Project #
Division
Wage & Hour Administration
Project Name and Location
Date Your Work Started:
Your Est. Completion Date:
Amount of Your Contract:
Dept. of Labor Project #:
1. Name of Employee
Specific Work Class
DAYS OF WORK WEEK
Code*
I
ncluding certificate
2. Permanent Domicile Address
Net
numbers for Electricians,
Total
Hourly
Gross
Total
Check #
(NO P.O. BOX or RURAL ROUTES ACCEPTED
Plumbers, Painters,
Amount
Powdermen, Asbestos
3. Mailing Address (if different from #2)
Hours
Rate Paid
Earnings
Deductions
Issued
DATE OF THE MONTH
Workers. Truck drivers include
Paid
truck license number.
Social Security Numbers MUST be included
Classification Code
Hours
1.
W
ST
E
Employee Name
Classification
E
Hours
SSN:
OT
K
1
2.
Cert. of Fitness #
FB
DATE OF THE MONTH
Truck License #
(if
applicable)
W
Union:
Hours
E
ST
3.
E
Hours
K
OT
Apprentice %
(If
2
applicable)
FB
DATE OF THE MONTH
Classification Code
1.
W
Hours
E
ST
Employee Name
Classification
E
SSN:
Hours
K
OT
2.
1
Cert. of Fitness #
FB
DATE OF THE MONTH
Truck License #
(if
applicable)
W
Union:
Hours
E
ST
3.
E
Hours
K
OT
Apprentice %
(If
2
applicable)
FB
Bi-Weekly Form, Page 1 - Effective 7/1/2003 Rev. May 2013
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