Fillable Massachusetts Weekly Certified Payroll Report Form printable pdf download

Massachusetts Weekly Certified Payroll Report Form

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MASSACHUSETTS WEEKLY CERTIFIED PAYROLL REPORT FORM

Company's Name:

Address:

Phone No.:

Payroll No.:

Employer's Signature:

Title:

Contract No:

Work Week Ending:

Tax Payer ID Number

Awarding Authority's Name:

Public Works Project Name:

Public Works Project Location:

Min. Wage Rate Sheet Number

General / Prime Contractor's Name:

Subcontractor's Name:

"Employer" Hourly Fringe Benefit Contributions

(B+C+D+E)

(A x F)

Project

Employee

Gross

Hourly

Health &

ERISA

Total

Hours

Hours Worked

is OSHA

Wages

(A)

Appr.

Base

Welfare

Pension

Supp.

Hourly

Employee Name & Complete

Work

Rate

Wage

Insurance

Plan

Unemp.

Prev. Wage

Check No.

All Other

certified

Total Gross

Address

Classification:

(%)

Su.

Mo.

Tu.

We.

Th.

Fr.

Sa.

(B)

(C)

(D)

(E)

(F)

(H)

(?)

Hours

Wages

YES

Are all apprentice employees identified above currently registered with the MA DLS's Division of Apprentice Standards?

For all apprentices performing work during the reporting period, attach a copy of the apprentice identification card issued

No apprentices are identified above

by the Massachusetts Department of Labor Standards / Division of Apprentice Standards.

NOTE: Pursuant to MGL c. 149, s. 27B, every contractor and subcontractor is required to submit a true and accurate copy of their certified weekly payroll records to the awarding

authority by first-class mail or e-mail. In addition, each weekly payroll must be accompanied by a statement of compliance signed by the employer. Failure to comply may result in the

commencement of a criminal action or the issuance of a civil citation.

Date Received by Awarding Authority

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