THE CITY OF NEW YORK • OFFICE OF THE COMPTROLLER • …

1 (1)(3)(5)(6)(7)(9)JAJAJAJAJAJAJA,20_____ THE CITY OF NEW york OFFICE OF THE COMPTROLLER BUREAU OF LABOR LAWEMPLOYER NAMEEMPLOYER ADDRESSEMPLOYER EMAIL ADDRESSEMPLOYER PHONE #EMPLOYER TAX #PROJECT NAMECERTIFIED PAYROLL REPORTCHECK IF PROJECT LABOR AGREEEMENT (PLA)PAYROLL #WEEK ENDING DATEGROSS PAY(THIS PROJECT)WAGESNAME OF PRIME CONTRACTOR, BUILDING OWNER OR UTILITYCONTRACT REGISTRATION #AGENCYAGENCY PIN #PROJECT OR BUILDING ADDRESS(2)(4)(8)(10)NET PAYHOURLY CONTRIBUTIONS TO BENEFIT FUNDS OR INDIVIDUAL ACCOUNTSALL OTHER BONA FIDE FRINGE BENEFITSEMPLOYER PROJECTED ANNUAL COSTEMPLOYEE PROJECTED ANNUAL HOURSANNUALIZED HOURLY RATEBONA FIDE FRINGE BENEFITSTOTAL GROSS PAY(ALL WORK)WITHHOLDINGS& DEDUCTIONSHOURS WORKED EACH DAYSTWORKER NAMEADDRESSLAST FOUR DIGITS OF SSNTRADE CLASSIFICATIONUNION LOCAL #JOURNEYPERSON OR APPRENTICE(NYS DOL REGISTERED)TIMETHIS PROJECT, CONTRACT OR BUILDINGALL WORK (PUBLIC AND PRIVATE)DAY AND DATETOTAL HOURSHOURLY RATE OF PAYOTOTSTSTOTOTSTSTOTOTSTSTOTOFFICER OR PRINCIPAL OF EMPLOYER (Print Name)

2 TITLESIGNATUREDATEFALSIFICATION OF THIS STATEMENT IS A PUNISHABLE OFFENSEThis certified payroll report has been prepared in accordance with the instructions for this form. I certify that the above information represents the hours worked by, wages paid to and bona fide fringe benefits provided to all of the workers employed by the above named employer on this project, contract or building during the period shown. I understand that falsification of this statement is a punishable offense.