Minnesota Department Of Labor And Industry Certified Payroll Form

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Minnesota Department of Labor and Industry Certified Payroll Form

This is a two part form consisting of Part 1 - Prevailing Wage Payroll Information listed below and the accompany Part 2 - Statement of Compliance. The contractor and

subcontractor(s) shall furnish these completed forms every two weeks to the contracting authority. Copies of the Prevailing Wage Payroll Information form and the Statement of

Compliance form are available at DLI.MN.GOV/LS/PrevWage.asp

All payrolls must be certified by attaching to each report a completed and executed Statement of Compliance.

Name of Contractor or

Prime Contractor Name

Subcontractor

Address & Telephone Number

Pay Period End Date

Project Name and Location

Contract Purchase Order Number

Payroll #

Day of Week & Date (xx/xx)

Labor Code and

Gross

-----------------

Total

Hrly

Amt

Employee Name, Address, &

Other

# of

Amt.

Identifying Number

Hrs

Rates

Earned

Fed

State

Total

Total Net

(Specify)

Exemp-

Earned

FICA

(DO NOT provide Social Security

This

Tax

Deductions

Wages Paid

Classification

This

tions

This

No.)

Title

Job

Pay

Hours Worked Each Day

Job

Period

*Pursuant to the Minnesota Government Data Practices Act, all of the data provided hereunder is public data, which is available to anyone upon request. DO NOT provide any confidential data such as

social security numbers, in part or whole, on this form. This data is collected pursuant to Minnesota Stat. §177.30 Sub. 4 and 177.43 Sub. 3. If you have questions regarding the Prevailing Wage Laws,

contact the Minnesota Department of Labor & Industry, 443 Lafayette Road Nl, St. Paul, MN 55155, Phone (651) 284-5091 or 1-800-DIAL-DLI (1-800-342-53584), TTY (651) 297-4198. The willful

falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal prosecution under state and/or federal law.