"Weekly Certified Payroll Report Form" - Massachusetts

Weekly Certified Payroll Report Form is a legal document that was released by the Massachusetts Department of Labor Standards - a government authority operating within Massachusetts.

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Download "Weekly Certified Payroll Report Form" - Massachusetts

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MASSACHUSETTS WEEKLY CERTIFIED PAYROLL REPORT FORM
Company's Name:
Address:
Phone No.:
Payroll No.:
Employer's Signature:
Title:
Contract No:
Work Week Ending:
Tax Payer ID Number
Awarding Authority's Name:
Public Works Project Name:
Public Works Project Location:
Min. Wage Rate Sheet Number
General / Prime Contractor's Name:
Subcontractor's Name:
"Employer" Hourly Fringe Benefit Contributions
(B+C+D+E)
(A x F)
Project
Project
Employee
Gross
Hourly
Health &
ERISA
Total
Hours
Hours Worked
is OSHA
Wages
(A)
Appr.
Base
Welfare
Pension
Supp.
Hourly
10
Employee Name & Complete
Work
Rate
Wage
Insurance
Plan
Unemp.
Prev. Wage
Check No.
All Other
certified
Total Gross
Address
Classification:
(%)
Su.
Mo.
Tu.
We.
Th.
Fr.
Sa.
(B)
(C)
(D)
(E)
(F)
(H)
(?)
Hours
Wages
YES
NO
Are all apprentice employees identified above currently registered with the MA DLS's Division of Apprentice Standards?
For all apprentices performing work during the reporting period, attach a copy of the apprentice identification card issued
No apprentices are identified above
by the Massachusetts Department of Labor Standards / Division of Apprentice Standards.
NOTE: Pursuant to MGL c. 149, s. 27B, every contractor and subcontractor is required to submit a true and accurate copy of their certified weekly payroll records to the awarding
authority by first-class mail or e-mail. In addition, each weekly payroll must be accompanied by a statement of compliance signed by the employer. Failure to comply may result in the
commencement of a criminal action or the issuance of a civil citation.
Date Received by Awarding Authority
Page ________of________
/
/
MASSACHUSETTS WEEKLY CERTIFIED PAYROLL REPORT FORM
Company's Name:
Address:
Phone No.:
Payroll No.:
Employer's Signature:
Title:
Contract No:
Work Week Ending:
Tax Payer ID Number
Awarding Authority's Name:
Public Works Project Name:
Public Works Project Location:
Min. Wage Rate Sheet Number
General / Prime Contractor's Name:
Subcontractor's Name:
"Employer" Hourly Fringe Benefit Contributions
(B+C+D+E)
(A x F)
Project
Project
Employee
Gross
Hourly
Health &
ERISA
Total
Hours
Hours Worked
is OSHA
Wages
(A)
Appr.
Base
Welfare
Pension
Supp.
Hourly
10
Employee Name & Complete
Work
Rate
Wage
Insurance
Plan
Unemp.
Prev. Wage
Check No.
All Other
certified
Total Gross
Address
Classification:
(%)
Su.
Mo.
Tu.
We.
Th.
Fr.
Sa.
(B)
(C)
(D)
(E)
(F)
(H)
(?)
Hours
Wages
YES
NO
Are all apprentice employees identified above currently registered with the MA DLS's Division of Apprentice Standards?
For all apprentices performing work during the reporting period, attach a copy of the apprentice identification card issued
No apprentices are identified above
by the Massachusetts Department of Labor Standards / Division of Apprentice Standards.
NOTE: Pursuant to MGL c. 149, s. 27B, every contractor and subcontractor is required to submit a true and accurate copy of their certified weekly payroll records to the awarding
authority by first-class mail or e-mail. In addition, each weekly payroll must be accompanied by a statement of compliance signed by the employer. Failure to comply may result in the
commencement of a criminal action or the issuance of a civil citation.
Date Received by Awarding Authority
Page ________of________
/
/