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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 .*FRINGE BENEFITS EXPLANATION (FB): Bona fide benefits contribution, except those required by Federal or StateLaw (unemployment tax, workers compensation, income taxes, etc.)

weekly payroll certification for public works projects contractor or subcontractor (please check one) all information must be completed bureau of labor law compliance prevailing wage division 7th & forster streets harrisburg, pa 17120 1-800-932 …

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