Certified Payroll Form - Alaska

This "Certified Payroll Form" is a document issued by the Alaska Department of Labor and Workforce Development specifically for Alaska residents with its latest version released on July 1, 2013.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Alaska Department of Labor and Workforce Development.

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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
S
M
T
W
TH
F
S
put N/A
number
Insurance
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Classification Code:
OT
Classification:
ST
Certificate #
FB
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
S
M
T
W
TH
F
S
put N/A
number
Insurance
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Classification Code:
OT
Classification:
ST
Certificate #
FB
Truck License #
Classification Code:
OT
Classification:
ST
Certificate #
FB
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,
o
(From Yakutat south)
North of N63
South of N63
o
Labor Standards & Safety, DOLWD
Labor Standards & Safety Div, 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.
(c) Each laborer, mechanic or field surveyor listed on
Date:
(2) That
(Contractor / Subcontractor)
this payroll has been paid, as indicated on the payroll, an
I
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

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