Free sampayro03.xls - Connecticut

In accordance with Connecticut General Statutes, 31-53 Certified Payrolls with a statement of compliance shall be submitted monthly to the contracting agency. CONTRACTOR NAME AND ADDRESS: Landon Corporation, 15 Conn. Avenue, Northford, CT 06472 PAYROLL NUMBER 1
PERSON/WORKER AND ADDRESS

PAYROLL CERTIFICATION FOR PUBLIC WORKS PROJECTS
WEEKLY PAYROLL
SUBCONTRACTOR NAME & ADDRESS R. Craft Electric 2 Main Street Yantic, CT 06389

Connecticut Department of Labor Wage and Workplace Standards Division 200 Folly Brook Blvd. Wethersfield, CT 06109
WORKER'S COMPENSATION INSURANCE CARRIER

Aetna
POLICY #

#BAC8888928 1/1/1997 xxxxxxxxx
GROSS PAY FOR THIS PREVAILING CHECK # AND RATE JOB NET PAY

Week-Ending Date 10/25/2005 APPR MALE/ RATE FEMALE % AND
RACE*

PROJECT NAME & ADDRESS State Office Building Renovation, 165 Capitol Avenue Hartford, CT 06106
WORK CLASSIFICATION

EFFECTIVE DATE: EXPIRATION DATE: TOTAL DEDUCTIONS

S

M

T

DAY AND DATE W TH

F

S

TRADE LICENSES TYPE & NUMBER

23

24 25 19 20 HOURS WORKED EACH DAY

21

Robert Craft 81 Maple Street Manchester, CT 06040

M/C

Electrician E-1 #0000000

8

8

8

8

Ronald Jones 212 Elm Street Norwich, CT 06380

65% M/B

Apprentice Electrician

8

8

8

8

8

Robert Larson 50 South Street Norwich, CT 06380

M/H

Electrician E-2 #0000000

8

8

8

Den Smith 1000 Lindsay Avenue Rogers, CT 06238

M/C

Electrician E-2 #0000000

8

8

8

8

8

TYPE OF GROSS PAY FRINGE FOR ALL BENEFITS WORK TOTAL FRINGE Per Hour PERFORMED 22 BENEFIT PLAN 1 through 6 THIS WEEK O-TIME CASH (see back) 1. $5.80 40 $30.75 2. $ Base Rate 3. $2.01 $1,582.80 4. $ 8 $8.82 5. $ Cash Fringe 6. $ 1. $ 40 $19.99 2. $ Base Rate 3. $ $1,464.48 4. $ $16.63 5. $ Cash Fringe 6. $ 1. $2.69 2. $9.36 24 $30.75 Base Rate 3. $2.01 $1,026.00 4. $ $ 5. $2.57 Cash Fringe 6. $ 1. $2.69 2. $ $30.75 40 Base Rate 3. $2.01 $2,171.64 4. $ 8 8 $11.93 5. $ Cash Fringe 6. $
S-TIME BASE HOURLY RATE

FEDERAL STATE

FICA

WITHWITHOTHER HOLDING HOLDING

$1,582.80

$1,582.80 #101

$xx.xx

$xx.xx

$xx.xx

$xx.xx

$1,464.48

$xxx.xx #102

$xx.xx

$xx.xx

$xx.xx

$xx.xx

$738.00

$xxx.xx #103

$xx.xx

$xx.xx

$xx.xx

$xx.xx

$2,171.64

$xxx.xx #104

9/1/2005
WWS-CP1

*IF REQUIRED *SEE REVERSE SIDE PAGE NUMBER
1 OF 1

*Fringe Benefits Explanation (P): Bona fide benefits paid to approved plans, funds or programs, except those required by Federal or State Law (unemployment tax, worker=s compensation, income taxes, etc.) Please specify the type of benefits provided: 1) Medical or hospital care x 2) Pension or retirement x 3) Life Insurance x 4) Disability 5) Vacation, holiday x 6) Other (please specify) CERTIFIED STATEMENT OF COMPLIANCE For the week ending date of 10/25/05 I, Robert Craft Electric , (hereafter known as Employer) in my capacity as President and state:

of R,. Craft (title) do hereby certify

All persons employed on said project have been paid the full weekly wages earned by them during the week in accordance with Connecticut General Statutes, section 31-53, as amended. Further, I hereby certify and state the following: A) The records submitted are true and accurate; B) The rate of wages paid to each mechanic, laborer or workman and the amount of payment or contributions paid or payable on behalf of each such employee to any employee welfare fund, as defined in Connecticut General Statutes, section 31-53 (h), are not less than the prevailing rate of wages and the amount of payment or contributions paid or payable on behalf of each such employee to any employee welfare fund, as determined by the Labor Commissioner pursuant to subsection Connecticut General Statutes, section 31-53 (d), and said wages and benefits are not less than those which may also be required by contract; C) The Employer has complied with all of the provisions in Connecticut General Statutes, section 31-53 (and Section 31-54 if applicable for state highway construction); D) Each such employee of the Employer is covered by a worker=s compensation insurance policy for the duration of his employment which proof of coverage has been provided to the contracting agency; E) The Employer does not receive kickbacks, which means an money, fee, commission, credit, gift, gratuity, thing of value, or compensation of any kind which is provided directly or indirectly, to any prime contractor, prime contractor employee, subcontractor, or subcontractor employee for the purpose of improperly obtaining or rewarding favorable treatment in connection with a prime contract or in connection with a prime contract or in connection with a subcontractor relating to a prime contract; and F) The Employer is aware that filing a certified payroll which he knows to be false is a class D felony for which the employer may be fined up to five thousand dollars, imprisoned for up to five years or both. Submitted on 10/25/05 Date

Signature President

***THIS IS A PUBLIC DOCUMENT, DO NOT INCLUDE SOCIAL SECURITY NUMBERS***