"Contractors Certified Payroll Form - Dasny"

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CONTRACTORS CERTIFIED PAYROLL FORM
NAME OF CONTRACTOR
OR SUBCONTRACTOR
ADDRESS
PAYROLL NO.
FOR WEEK ENDING
PROJECT AND LOCATION
PROJECT OR CONTRACT NO
.
(7)
(3) DAY AND DATE
(8)
(1)
(2)
(4)
(5)
(6)
Deduct ions
Net
Name, Address, and
Work
Wages
Last four (4) digits of
Classification
Total
Rate
Gross
With
Total
Paid
Social Security Number
Hours
of pay
Amount
FICA
Holding
Other
Deduct-
For Week
of Employee
Earned
HOURS WORKED EACH DAY
Tax
ions
O
S
O
S
O
S
O
S
O
S
O
S
O
S
O
S
O
S
O
S
10/31/12
Page 1
CONTRACTORS CERTIFIED PAYROLL FORM
NAME OF CONTRACTOR
OR SUBCONTRACTOR
ADDRESS
PAYROLL NO.
FOR WEEK ENDING
PROJECT AND LOCATION
PROJECT OR CONTRACT NO
.
(7)
(3) DAY AND DATE
(8)
(1)
(2)
(4)
(5)
(6)
Deduct ions
Net
Name, Address, and
Work
Wages
Last four (4) digits of
Classification
Total
Rate
Gross
With
Total
Paid
Social Security Number
Hours
of pay
Amount
FICA
Holding
Other
Deduct-
For Week
of Employee
Earned
HOURS WORKED EACH DAY
Tax
ions
O
S
O
S
O
S
O
S
O
S
O
S
O
S
O
S
O
S
O
S
10/31/12
Page 1