Minnesota Department Of Labor And Industry Certified Payroll Form Page 2
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3MINNESOTA DEPARTMENT OF LABOR & INDUSTRY
Part 2 Statement of Compliance
REPORT NUMBER
STATE PROJECT NAME AND LOCATION
DATE
CONTACTING AUTHORITY
PROJECT
GENERAL CONTRACTOR
CONTRACTOR/SUBCONTRACTOR
PHONE NUMBER
CONTRACT PURCHASE ORDER NUMBER
ADDRESS
CITY/STATE
ZIP
TYPE OF WORK
(Complete as described on solicitation documents.)
STATEMENT WITH RESPECT TO COMPLIANCE AND WAGES PAID
I,
do hereby state:
(Name of signatory party)
(Title- Owner or Officer)
(1) That I pay or supervise the payment of the persons employed by
on said Contract; that during the payroll period commencing on the
day of
of the year
, and
ending the
day of
of the year
, there were
employees performing work on said
Contract. That all persons performing work under said Contract are listed on the payroll and have been paid the full prevailing
wages for all hours worked under said Contract, that no rebates and or deductions have or will be made either directly or
indirectly to or on behalf of said
(Contractor or Subcontractor)
from the full wages earned by any person, other than permissible deductions as defined in Minnesota Statutes 177.24, Subdivision
4, 181.06, and 181.79, issued by the Minnesota Commissioner of Labor and Industry and described below:
DESCRIBE LEGAL DEDUCTIONS
(2) That the payroll submitted under said Contract is complete and accurate; that the wage rate(s) of the laborer(s), mechanic(s), and
worker(s) performing work under said Contract is (are) paid according to the wage determination(s) and labor provisions
incorporated in said Contract and according to applicable laws; that wages paid to laborer(s) mechanic(s), and worker(s) performing
work under said Contract is at least the prevailing wage rate for the most similar classification of labor performed as defined under
applicable law; and that the laborer(s), mechanic(s), and worker(s) performing work under said Contract is (are) paid for all hours
in excess of the prevailing hours at a rate of at least one and one-halftimes the applicable base rate of pay.
(3) That any apprentices employed during said payroll period are duly registered in a bona fide apprenticeship program registered with
the Minnesota Department of Labor and Industry, or are registered with the Bureau of Apprenticeship and Training; United States
Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO ANY APPROVED PLANS, FUNDS, OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer, worker or mechanic listed on said payroll, payments
to current, bona fide fringe benefit programs as set forth in paragraph 4(d), have been or will be made to the
program's administrators as set forth in paragraph 4(e) for the benefit of said employees, except as noted in Section
4(c).
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH TO ALL EMPLOYEES
Each laborer, worker, or mechanic listed on said payroll has been paid, as indicated on the payroll, an amount not
less than the sum of the applicable basic rate plus the fringe rate as listed in the appropriate wage determination
incorporated into said Contract.
NOTE- FRINGE BENEFIT SECTIONS C, D, E AND SIGNATURE BLOCK ARE ON NEXT PAGE
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