Free payroll041.xls - Connecticut

[New] In accordance with Section 31-53b(a) of the C.G.S. each contractor shall provide a copy of the OSHA 10 Hour Construction Safety and Health Card for each employee, to be attached to the first certified payroll on the project.

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:

PAYROLL CERTIFICATION FOR PUBLIC WORKS PROJECTS
WEEKLY PAYROLL
SUBCONTRACTOR NAME & ADDRESS

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

POLICY #

PAYROLL NUMBER

Week-Ending Date

PROJECT NAME & ADDRESS
EFFECTIVE DATE: EXPIRATION DATE: WORK CLASSIFICATION Trade License Type & Number - OSHA
10 Certification Number

PERSON/WORKER, APPR MALE/ ADDRESS and SECTION RATE FEMALE % AND RACE*

S

M

T

DAY AND DATE W TH

F

S

HOURS WORKED EACH DAY

TYPE OF FRINGE BENEFITS TOTAL FRINGE Per Hour Total BENEFIT PLAN 1 through 6 O/T Hours CASH (see back) 1. $ S-TIME $ 2. $ Base Rate 3. $ 4. $ O-TIME $ 5. $ Cash Fringe 6. $ 1. $ S-TIME $ 2. $ Base Rate 3. $ 4. $ O-TIME $ 5. $ Cash Fringe 6. $ 1. $ S-TIME $ 2. $ Base Rate 3. $ 4. $ O-TIME $ 5. $ Cash Fringe 6. $ 1. $ S-TIME 2. $ $ Base Rate 3. $ 4. $ O-TIME
Total ST

Hours

BASE HOURLY RATE

GROSS PAY TOTAL DEDUCTIONS FOR ALL FEDERAL STATE WORK PERFORMED THIS WEEK FICA WITHWITHHOLDING HOLDING

GROSS PAY FOR THIS PREVAILING CHECK # AND RATE JOB NET PAY

LIST
OTHER

$
Cash Fringe 7/13/2009
WWS-CP1

5. $ 6. $ PAGE NUMBER
OF

*IF REQUIRED *SEE REVERSE SIDE

OSHA 10 ~ATTACH CARD TO 1ST CERTIFIED PAYROLL

*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 2) Pension or retirement 3) Life Insurance

4) Disability 5) Vacation, holiday 6) Other (please specify)

CERTIFIED STATEMENT OF COMPLIANCE
For the week ending date of I, Employer) in my capacity as of , , (hereafter known as (title) do hereby certify and state:

Section A: 1. 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 any 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 contractor in connection with a subcontractor relating to a prime contractor; 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.

2. OSHA~The employer shall affix a copy of the construction safety course, program or training completion document to the certified payroll required to be submitted to the contracting agency for this project on which such employee's name first appears. (Signature) (Title) Submitted on (Date)

Section B: Applies to CONNDOT Projects ONLY
That pursuant to CONNDOT contract requirements for reporting purposes only, all employees listed under Section B who performed work on this project are not covered under the prevailing wage requirements defined in Connecticut General Statutes Section 31-53.

(Signature)

(Title)

Submitted on (Date)

Note: CTDOL will assume all hours worked were performed under Section A unless clearly delineated as Section B WWS-CP1 as such. Should an employee perform work under both Section A and Section B, the hours worked and wages paid must be segregated for reporting purposes. ***THIS IS A PUBLIC DOCUMENT*** ***DO NOT INCLUDE SOCIAL SECURITY NUMBERS***

Weekly Payroll Certification For Public Works Projects (Continued)

PAYROLL CERTIFICATION FOR PUBLIC WORKS PROJECTS
WEEKLY PAYROLL

Week-Ending Date: Contractor or Subcontractor Business Name:

PERSON/WORKER, ADDRESS and SECTION

APPR MALE/ RATE FEMALE % AND RACE*

WORK CLASSIFICATION S
Trade License Type & Number - OSHA 10 Certification Number

M

T

DAY AND DATE W TH

F

S

Total ST BASE HOURLY Hours RATE TOTAL FRINGE BENEFIT PLAN O/T Hours CASH Total
S-TIME

HOURS WORKED EACH DAY

TYPE OF GROSS PAY TOTAL DEDUCTIONS GROSS PAY FOR FRINGE FOR ALL WORK FEDERAL STATE THIS PREVAILING CHECK # AND BENEFITS PERFORMED RATE JOB NET PAY LIST Per Hour THIS WEEK 1 through 6 FICA WITHWITHOTHER (see back) HOLDING HOLDING 1. $ 2. $ 3. $ 4. $ 5. $ 6. $ 1. $ 2. $ 3. $ 4. $ 5. $ 6. $ 1. $ 2. $ 3. $ 4. $ 5. $ 6. $ 1. $ 2. $ 3. $ 4. $ 5. $ 6. $ 1. $ 2. $ 3. $ 4. $ 5. $ 6. $

$
Base Rate

O-TIME

$
Cash Fringe
S-TIME

$
Base Rate

O-TIME

$
Cash Fringe
S-TIME

$
Base Rate
O-TIME

$
Cash Fringe
S-TIME

$
Base Rate

S-TIME

$
Cash Fringe
S-TIME

$
Base Rate
S-TIME

$
Cash Fringe
*IF REQUIRED

7/13/2009
WWS-CP2

NOTICE: THIS PAGE MUST BE ACCOMPANIED BY A COVER PAGE (FORM # WWS-CP1)

PAGE NUMBER

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