Transcription of CERTIFIED PAYROLL REPORT
1 CERTIFIED PAYROLL REPORT . Employer Name & Address Name of General / Prime Contractor Project Name & Location Contracting Public Authority Points North (CPW Sample Reports) Points North (CPW Sample Reports) Stable Work 2904. Columbus, OH. 371 Canal Park Dr Columbus, OH 43085. Check if subcontractor Week Ending PAYROLL # Project Number 11/28/2010 1 1 1. Page_____Of_____ 2904. 2. 4. 5. 6. 7. Fringes: 8. Total 9. Total 10. 11. 12. 1. Employee Name, Address Work 3. Hours Worked - Day & Date Project Base Project Cash Hours Gross Taxes Other NET. and Social Security Number Class Total Hrs. Rate Gross Approved Plans All Jobs All Jobs Withheld Deducts Paid Cash & Approved Plans Mon Tue Wed Thu Fri Sat Sun H&W Pens Vac App Other 11/22 11/23 11/24 11/25 11/26 11/27 11/28. Hiko, Lee Laborer OT. 120 Jones St $ $ $ $ $ $ $ $ $ $ Columbus, OH 43085 ST 6 0 0 0 0 0 0 6 Lew, Matt Operator 0 0 0 0 0 0 OT. 84 Amburst Rd 0 0 0 0 0 0 $ $ $ $ $ $ $ $ $ $ Columbus, OH 43085.
2 ST 8 8 8 8 8 0 0 40 Ritz, Jes Electricia n OT. 0 0 0 0 2 0 0 2 41 Cattail Lane $ $ $ $ $ $ $ $ $ $ Columbus, OH 43085. ST 0 0 0 0 6 0 0 6 Wacki, Bill Laborer OT. 10 Wards Rd $ $ $ $ $ $ $ $ $ $ Columbus, OH 43085. ST 0 8 8 0 0 0 0 16 OT. ST. OT. ST. OT. ST. OT. ST. 2/15/2011. Date_____My signature on this form signifies that I pay, or supervise the payment of the employees shown above. I am certifying: 1) That during the pay period reported on this form, all hours worked on this project have been paid at the appropriate prevailing wage rate for the class of work done. 2) That the fringe benefits have been paid as indicated above. 3) That no rebates or deductions have been or will be made, directly or indirectly from the total wages earned, other than permissable deductions as defined in the Ohio Revised Code Chapter 4115. 4) That apprentices are registered with the Department of Labor, Bureau of Apprenticeship and Training. The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal prosecution.
3 Name and Title _____. John Smith Owner Signature _____.
