Alaska Certified Payroll Form Download Printable PDF

CERTIFIED PAYROLL

Alaska Department of Labor and Workforce

Development

Labor Standards and Safety Division

Wage and Hour Administration

Contractor Name

_____Contractor

_____SubContractor

Address

Phone

Contractor License No.

Week Ending

Contracting Agency Project #

Project Name and Location

Date Work Started

Est. Completion Date

Payroll No.

Dept. Labor Project #

Contract Amount

Date of the Month

Name, SSN, Permanent Domicile Address

Specific Work Class Code

DEDUCTIONS

Union

(NO P.O. BOX or RURAL ROUTES ACCEPTED)

Including certificate #'s for

Apprentice

Member-

Total

Gross

Electricians, Plumbers,

and Mailing Address (if different) for each

OTHER

Hourly

Painters, Powderman,

(%) if

ship?

Day of the Week

Hours

Amount

(EXPLAIN)

employee

Rate Paid

FED W/H

UNION

Asbestos Workers. Truck

Applicable

If NONE

Worked

Earned

FICA

ESD

Garnish or

TAX

DUES

Social Security numbers MUST be included

drivers include truck license

Medical

put N/A

number

Insurance

Classification Code:

Classification:

Certificate #

Truck License #

Classification Code:

Classification:

Certificate #

Truck License #

Classification Code:

Classification:

Certificate #

Truck License #

Classification Code:

Classification:

Certificate #

Truck License #

Classification Code:

Classification:

Certificate #

Truck License #

Classification Code:

Classification:

Certificate #

Truck License #

Weekly Certified Payroll Form, Pg 1 of 2 - Revised July 2013

CERTIFIED PAYROLL

Alaska Department of Labor and Workforce

Development

Labor Standards and Safety Division

Wage and Hour Administration

Contractor Name

_____Contractor

_____SubContractor

Address

Phone

Contractor License No.

Week Ending

Contracting Agency Project #

Project Name and Location

Date Work Started

Est. Completion Date

Payroll No.

Dept. Labor Project #

Contract Amount

Date of the Month

Name, SSN, Permanent Domicile Address

Specific Work Class Code

DEDUCTIONS

Union

(NO P.O. BOX or RURAL ROUTES ACCEPTED)

Including certificate #'s for

Apprentice

Member-

Total

Gross

Electricians, Plumbers,

and Mailing Address (if different) for each

OTHER

Hourly

Painters, Powderman,

(%) if

ship?

Day of the Week

Hours

Amount

(EXPLAIN)

employee

Rate Paid

FED W/H

UNION

Asbestos Workers. Truck

Applicable

If NONE

Worked

Earned

FICA

ESD

Garnish or

TAX

DUES

Social Security numbers MUST be included

drivers include truck license

Medical

put N/A

number

Insurance

Classification Code:

Classification:

Certificate #

Truck License #

Classification Code:

Classification:

Certificate #

Truck License #

Classification Code:

Classification:

Certificate #

Truck License #

Classification Code:

Classification:

Certificate #

Truck License #

Classification Code:

Classification:

Certificate #

Truck License #

Classification Code:

Classification:

Certificate #

Truck License #

Weekly Certified Payroll Form, Pg 1 of 2 - Revised July 2013

STATEMENT OF COMPLIANCE

CERTIFIED PAYROLL

SSN MUST be listed for each employee on payroll

FORM 07-6058

Contractors & Subcontractors Please Note!!!

8 AAC 30.020 CERTIFIED PAYROLL. (a) All Contractors (including owner/operators) who perform work on a public construction contract for the state or political subdivision of the state

shall file with the Department a certified payroll (Form 07-6058) before Friday of each week that covers the preceding week.

(b) The certified payroll shall be submitted to the Department's regional office in which the work is performed.

Region IIA, Southeast Alaska,

Region I,

Region II,

(From Yakutat south)

North of N63

South of N63

Labor Standards & Safety, DOLWD

Labor Standards & Safety Div, DOLWD

P. O. Box 111149

675 7th Ave., Station J-1

1251 Muldoon Road, Suite 113

1111 W. 8th Street, Rm 302

Fairbanks, AK 99701-4593

Anchorage, AK 99504

Juneau, AK 99811-1149

(907) 451-2886 Fax: (907) 451-2885

(907) 269-4900 Fax: (907) 269-4915

(907) 465-4842 Fax: (907) 465-3584

In lieu of submitting Form 07-6058, contractors may submit his/her payroll form. THE FORM MUST CONTAIN SOCIAL SECURITY NUMBERS FOR EACH EMPLOYEE.

The contractor's payroll record must contain the same information required on this form.

Sec. 35.05.040 requires that all contractors or subcontractors who perform work on a public construction contract for the state or a political subdivision of the state shall, BEFORE

FRIDAY OF EACH WEEK, file with the Department of Labor and Workforce Development (DOLWD), a sworn affidavit for the previous week, setting out in detail the

number of workers employed, wages paid each week, job classification of each employee, hours worked each day and week, and other information which the DOLWD requires.

CONTRACTORS WHO DISREGARD THEIR OBLIGATIONS TO THEIR EMPLOYEES, INCLUDING PAYMENT OF THE APPROPRIATE PREVAILING RATES OF PAY, UNCONDITIONAL PAYMENT,

AND PAYMENT NOT LESS THAN ONCE A WEEK MAY BE DEBARRED FROM PUBLIC CONSTRUCTION.

□

Date:

(2) That

(Contractor / Subcontractor)

this payroll has been paid, as indicated on the payroll, an

do hereby state

is in full compliance with the provisions set forth in AS 36.10,

amount not less than the sum of the applicable basic hourly

(Name of Signatory Party)

(Title)

which requires employment preference for Alaska residents as

wage rate plus the amount of the required fringe benefits as

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

outlined in AS 36.95.010; and

currently published by DOLWD, except as noted in Section

on the

(3) That any payrolls otherwise under this contract required

6(d).

□

(Contractor / Subcontractor)

to be submitted for the above period are correct and complete;

(d) Exceptions:

; that during the payroll

that the wage rates for laborers, mechanics or field surveyors

Exception (Craft)

Explanation

(Building or Work)

contained herein are not less than the current applicable wage

period commencing on

, and ending on

rates established by the DOLWD; that the classification set forth

(date)

therein for each laborer, mechanic or field surveyor conforms

, all persons employed on said project have

with the work performed; and

(date)

(4) That any apprentices employed in the above period are

Remarks:

been paid full weekly wages earned, that no rebates have

duly registered in a bona fide apprenticeship program

been or will be made either directly or indirectly to or on behalf of

registered with the State apprenticeship agency recognized by

said

the Bureau of Apprenticeship and Training, United States

Department of Labor, or if no such agency exists in the State,

(Contractor / Subcontractor)

are registered with the Bureau of Apprenticeship and Training,

United States Department of Labor; or

from the full weekly wages earned by an person, and that no

(5) That I am a bona fide owner/operator and that my

deductions have been made either directly or indirectly from the

contract amount meets or exceeds the prevailing wage for each

The willful falsification of any of the above information may

full wages earned by any person, other than permissible

hour I have worked. My last progress payment was received on

subject the contractor or subcontractor to civil or criminal

prosecution. See Section 1001 of Title 18 and Section 231 of

deductions, on projects covered by Alaska Statute 36 as defined

For

the United States Code. Also see AS 36.05.060.

in regulations issued by the Commissioner of Labor; or on Federal

(6) That where fringe benefits are paid to approved plans,

□

Projects as defined in Regulations, Part 3 (29 CFR Subtitle A),

funds or programs: (check all applicable items)

(a) In addition to the basic hourly wage rates paid to each

issued by the Secretary of Labor under the Copeland Act, as

amended (48 Stat. 948; 63 Stat. 108; 72 Stat. 967; 76 Stat. 357;

laborer, mechanic or field surveyor listed on this payroll,

40 USC 276 (c), and described below:

payments of fringe benefits as currently published by DOLWD

have been or will be made to a union trust.

□

(b) In addition to the basic hourly wage rates paid to each

Signature (original signature required)

laborer, mechanic or field surveyor listed on this payroll,

payments of fringe benefits as currently published by DOLWD

and;

have been or will be made to the appropriate programs for the

benefit of such workers, except as noted in Section 6(d) below.

Fringe benefit payments will be made at least monthly to an

Name & Title (print or type)

approved plan. The name of the plan is:

Rev. July 2013

Weekly Form pg. 2 - Effective 7/1/2003

"Certified Payroll Form" - Alaska

Download "Certified Payroll Form" - Alaska

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