PUBLIC WORKS PAYROLL REPORTING FORM

California Department of PUBLIC WORKS PAYROLL REPORTING form . Industrial Relations Page _____ of _____. NAME OF CONTRACTOR: CONTRACTOR'S LICENSE NO.: ADDRESS: OR SUBCONTRACTOR: SPECIALITY LICENSE NO.: PAYROLL NO.: FOR WEEK ENDING: SELF-INSURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.: (4) DAY (5) (6) WORKERS' COMPENSATION POLICY NO.: PROJECT AND LOCATION: (9). (1) (2) (3) M T W TH F S S (7) (8). HOURLY. DATE. NO. OF WITH- NAME, ADDRESS AND work TOTAL RATE GROSS AMOUNT. EXEMPTIONS. NET WGS CHECK. SOCIAL SECURITY NUMBER CLASSIFICATION HOURS OF PAY EARNED DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS PAID FOR NO. HOLDING. OF EMPLOYEE WEEK. HOURS WORKED EACH DAY. THIS ALL FED. FICA STATE VAC/ HEALTH. TAX (SOC. SEC.) TAX SDI HOLIDAY & WELF. PENSION. PROJECT PROJECTS. S 0. TRAV/ TOTAL. TRAING. FUND DUES subs . SAVINGS OTHER* DEDUC- ADMIN TIONS. O. THIS ALL FED. FICA STATE VAC/ HEALTH.

SUBS. SAVINGS OTHER * TOTAL DEDUC-TIONS : O S = STRAIGHT TIME *OTHER – Any other deductions, contributions and/or payments whether or not included or required by prevailing wage determinations must be separately listed. Use extra sheet(s) if necessar y ; CERTIFICATION MUST be completed

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