Minnesota Department Of Labor And Industry Certified Payroll Form Page 3
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3(c) EXCEPTIONS
EMPLOYEE NAME
CLASSIFICATION/OCCUPATION
EXPLANATION
DOLLARS CONTRIBUTED PER HOUR
(d) BENEFIT PROGRAM INFORMATION in
(Must be completed if 4(a) is checked.)
A
PPRENTI-
PROGRAM TITLE, CLASSIFICATION TITLE, OR
HEALTH/
VACATION/
PENSION
OTHER
CESHIP
INDIVIDUAL EMPLOYEES
WELFARE
HOLIDAY
INCLUDE TITLE
TRAINING
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(e) BENEFIT PROGRAM INFORMATION (Must be completed if 4(a) is checked.)
NAME
&
ADDRESS OF FRINGE BENEFIT
BENEFIT ACCOUNT
THIRD PARTY TRUSTEE
TELEPHONE NUMBER
FUND, PLAN, OR PROGRAM
NUMBER
AND/OR CONTACT PERSON
ADMINISTRATOR
The willful falsification of any of the above statements may subject the contractor or subcontractor to
civil or criminal prosecution under federal and/or state law.
NAME AND TITLE OF OWNER OR OFFICER
SIGNATURE
As a representative of the contractor submitting the payroll identified above, I hereby certify that the payroll is true and correct to
the best of my knowledge.
NOTE: For information regarding this form, submission of payroll records, or copies of the laws stated above,
contact the Minnesota Department of Labor and Industry, 443 Lafayette Road N., St. Paul, MN 55155,
Phone: (651) 284-5091 or 1-800-DIAL-DLI (1-800-342-5354), TTY: (651) 297-4198.
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