"Payroll Certification for Covered Service Worker Contracts" - Connecticut

Payroll Certification for Covered Service Worker Contracts is a legal document that was released by the Connecticut Department of Labor - a government authority operating within Connecticut.

Form Details:

  • Released on February 20, 2004;
  • The latest edition currently provided by the Connecticut Department of Labor;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut Department of Labor.

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Download "Payroll Certification for Covered Service Worker Contracts" - Connecticut

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PAYROLL CERTIFICATION FOR COVERED SERVICE WORKER CONTRACTS
Connecticut Department of Labor
In accordance with Connecticut General Statute, Section 31-57f
Certified Payrolls with a statement of compliance
Wage and Workplace Standards Division
WEEKLY PAYROLL
200 Folly Brook Blvd.
shall be submitted monthly to the contracting state agent upon request.
Wethersfield, CT 06109
REQUIRED EMPLOYER/CONTRACTOR NAME AND ADDRESS:
CONTRACTING STATE AGENT/STATE AGENCY:
TERM OF CONTRACT:
PAYROLL NUMBER
WEEK-ENDING DATE
CONTRACT DESCRIPTION AND BID NUMBER:
MALE/
WORK
DAY AND DATE
S-TIME
BASE HOURLY
TYPE OF
GROSS PAY
TOTAL DEDUCTIONS
GROSS PAY FOR
CHECK # AND
FEMALE
CLASSIFICATION
S
M
T
W
TH
F
S
RATE
FRINGE BENEFITS FOR ALL WORK
FEDERAL STATE
THIS SERVICE
NET PAY
EMPLOYEE NAME AND ADDRESS
AND
Per Hour
PERFORMED
CONTRACT JOB
RACE*
TOTAL FRINGE
1 through 6
THIS WEEK
TRADE LICENSES
BENEFIT PLAN
(see back)
FICA
WITH-
WITH-
OTHER
TYPE & NUMBER
HOURS WORKED EACH DAY
O-TIME
CASH
HOLDING HOLDING
1. $
$
2. $
Base Rate
3. $
4. $
$
5. $
Cash Fringe
6. $
1. $
$
2. $
Base Rate
3. $
4. $
$
5. $
Cash Fringe
6. $
1. $
$
2. $
Base Rate
3. $
4. $
$
5. $
Cash Fringe
6. $
1. $
2. $
$
Base Rate
3. $
4. $
$
5. $
Cash Fringe
6. $
1. $
$
2. $
Base Rate
3. $
4. $
$
5. $
Cash Fringe
6. $
*IF REQUIRED
PAGE NUMBER
OF
2/20/2004
*SEE REVERSE SIDE
PAYROLL CERTIFICATION FOR COVERED SERVICE WORKER CONTRACTS
Connecticut Department of Labor
In accordance with Connecticut General Statute, Section 31-57f
Certified Payrolls with a statement of compliance
Wage and Workplace Standards Division
WEEKLY PAYROLL
200 Folly Brook Blvd.
shall be submitted monthly to the contracting state agent upon request.
Wethersfield, CT 06109
REQUIRED EMPLOYER/CONTRACTOR NAME AND ADDRESS:
CONTRACTING STATE AGENT/STATE AGENCY:
TERM OF CONTRACT:
PAYROLL NUMBER
WEEK-ENDING DATE
CONTRACT DESCRIPTION AND BID NUMBER:
MALE/
WORK
DAY AND DATE
S-TIME
BASE HOURLY
TYPE OF
GROSS PAY
TOTAL DEDUCTIONS
GROSS PAY FOR
CHECK # AND
FEMALE
CLASSIFICATION
S
M
T
W
TH
F
S
RATE
FRINGE BENEFITS FOR ALL WORK
FEDERAL STATE
THIS SERVICE
NET PAY
EMPLOYEE NAME AND ADDRESS
AND
Per Hour
PERFORMED
CONTRACT JOB
RACE*
TOTAL FRINGE
1 through 6
THIS WEEK
TRADE LICENSES
BENEFIT PLAN
(see back)
FICA
WITH-
WITH-
OTHER
TYPE & NUMBER
HOURS WORKED EACH DAY
O-TIME
CASH
HOLDING HOLDING
1. $
$
2. $
Base Rate
3. $
4. $
$
5. $
Cash Fringe
6. $
1. $
$
2. $
Base Rate
3. $
4. $
$
5. $
Cash Fringe
6. $
1. $
$
2. $
Base Rate
3. $
4. $
$
5. $
Cash Fringe
6. $
1. $
2. $
$
Base Rate
3. $
4. $
$
5. $
Cash Fringe
6. $
1. $
$
2. $
Base Rate
3. $
4. $
$
5. $
Cash Fringe
6. $
*IF REQUIRED
PAGE NUMBER
OF
2/20/2004
*SEE REVERSE SIDE
*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,
of
(hereafter known as
Employer) in my capacity as
(title) do hereby certify and state:
All persons employed on said project have been paid the full weekly wages earned by them during the
week in accordance with Connectiut General Statute Section 31-57f. Further, I hereby certify and
state the following:
A) The records submitted are true and accurate;
B) The rate of wages paid to each employee is not less than the standard rate of wages as
determined by the Labor Commissioner pursuant to section (e);
C) The Employer has complied with all of the provisions of Section 1, and
D) The employer is aware that filing a certified payroll which it 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.
Submitted on
(Date)
(Signature)
(Title)
***THIS IS A PUBLIC DOCUMENT***
***DO NOT INCLUDE SOCIAL SECURITY NUMBERS***
PAYROLL CERTIFICATION FOR COVERED SERVICE WORKER CONTRACTS
WEEKLY PAYROLL CERTIFICATION
WEEK-ENDING DATE:
WEEKLY PAYROLL
MALE/
WORK
DAY AND DATE
S-TIME
BASE HOURLY
TYPE OF FRINGE
GROSS PAY
TOTAL DEDUCTIONS
GROSS PAY FOR
CHECK # AND
FEMALE
CLASSIFICATION
S
M
T
W
TH
F
S
RATE
BENEFITS
FOR ALL WORK
FEDERAL STATE
THIS SERVICE
NET PAY
EMPLOYEE NAME AND ADDRESS
AND
Per Hour
PERFORMED
CONTRACT JOB
RACE*
TOTAL FRINGE
1 through 6
THIS WEEK
TRADE LICENSES
BENEFIT PLAN
(see back)
FICA
WITH-
WITH-
OTHER
TYPE & NUMBER
HOURS WORKED EACH DAY
O-TIME
CASH
HOLDING HOLDING
1. $
S-Time:
$
2. $
Base Rate
3. $
O-Time:
4. $
$
5. $
Cash Fringe
6. $
1. $
S-Time:
$
2. $
Base Rate
3. $
O-Time:
4. $
$
5. $
Cash Fringe
6. $
1. $
S-Time:
$
2. $
Base Rate
3. $
O-Time:
4. $
$
5. $
Cash Fringe
6. $
1. $
S-Time:
$
2. $
Base Rate
3. $
O-Time:
4. $
$
5. $
Cash Fringe
6. $
1. $
S-Time:
$
2. $
Base Rate
3. $
O-Time:
4. $
$
5. $
1. $
S-Time:
$
2. $
Base Rate
3. $
4. $
O-Time:
$
5. $
Cash Fringe
6. $
*IF REQUIRED
PAGE NUMBER
OF
2/20/2004
NOTICE: THIS PAGE MUST BE ACCOMPANIED BY A COVER PAGE
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