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WEEKLY PAYROLL CERTIFICATION FOR PUBLIC WORKS …

LLC-25 REV 10-03 (Page 1) WEEKLY PAYROLL CERTIFICATION FOR PUBLIC WORKS PROJECTSC ontractor or Subcontractor (Please check one) ALL INFORMATION MUST BE COMPLETEDBUREAU OF LABOR LAW COMPLIANCEPREVAILING WAGE DIVISION7TH & FORSTER STREETSHARRISBURG, PA 171201-800-932-0665 CONTRACTORSUBCONTRACTORADDRESSADDRESSPAY ROLL NUMBER WEEK ENDING DATEPROJECT AND LOCATIONPROJECT SERIAL #PROJECT #EMPLOYEE (%)WORKCLASSIFICATIONDAY AND DATEHOURS WORKED EACH DAYS-TIME0-TIMEBASEHOURLYRATETOTAL FRINGEBENEFITS(C=Cash)(FB=Contributions) *TOTALDEDUCTIONSGROSS PAYFORPREVAILINGRATE JOB(S)CHECK # C:FB: C:FB: C:FB: C:FB: C:FB:*SEE REVERSE SIDEPAGE NUMBER _____ OF _____THE NOTARIZATION MUST BE COMPLETED ON FIRST AND LAST SUBMISSIONS ONLY. ALL OTHERINFORMATION MUST BE COMPLETED WEEKLY .

(b) No part of this contract has been or will be subcontracted to any subcontractor if such subcontractor or any firm, corporation or partnership in which such subcontractor has an interest is debarred pursuant to the aforementioned statute. 3. The undersigned certifies that:

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SAMPLE SAFETY COMMITTEE FUNCTIONS WITH …

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:: Common Sense - dli.pa.gov

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