Fillable Nyc Payroll Form in PDF

Department of Labor Bureau of Public Work

WEEKLY PAYROLL

For Contractor's Optional Use. The use of this form meets payroll notification requirements; as stated on the Payroll Records Notification.

NAME OF CONTRACTOR

SUBCONTRACTOR

ADDRESS

FEIN

FOR WEEK ENDING

PROJECT AND LOCATION

PROJECT OR CONTRACTOR NO.

(1)

NAME, ADDRESS, AND

LAST 4 DIGITS OF SOCIAL SECURITY NUMBER

OF EMPLOYEE

(2)

NO. OF

WITH-

HOLDINGS

(3)

WORK

CLASSIFICATION

ST

or

OT

4) DAY AND DATE

HOURS WORKED EACH DAY

(5)

TOTAL

HOURS

(6)

RATE

OF

PAY

(7) GROSS

AMOUNT

EARNED

(a)

(9)

NET WAGES

PAID

FOR WEEK

Date

I

do hereby state:

(1) That I pay or supervise the payment of the persons employed by

all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said

from the full

(Contractor or Subcontractor)

weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible deductions as defined in Articles 8 and 9 and described below:

(2)That any payrolls submitted for the above period are correct and complete; that the wage rates for laborers, workers, or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer, worker or mechanic conform with the work he/she performed.

(3)That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.

(4)That:

(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS, OR PROGRAMS

- In addition to the basic hourly wage rates paid to each laborer, worker or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the

benefit of such employees, except as noted in Section 4(c).

(b) WHERE FRINGE BENEFITS ARE PAID IN CASH

- Each laborer, worker, or mechanic listed in the above-referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in Section 4(c) below.

(c) EXCEPTIONS

REMARKS:

SIGNATURE

THE WILLFUL FALSIFICATION OF ANY Of THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR SUBCONTRACTOR

TO CIVIL OR CRIMINAL PROSECUTION. SEE ARTICLES 8 AND 9.