"Payroll Report Form" - New York City

Payroll Report Form is a legal document that was released by the Office of the New York City Comptroller - a government authority operating within New York City.

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Download "Payroll Report Form" - New York City

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THE CITY OF NEW YORK
OFFICE OF THE COMPTROLLER
BUREAU OF LABOR LAW
PAYROLL REPORT
NAME OF PRIME CONTRACTOR
AGENCY
TO BE SUBMITTED WITH REQUISITION FOR PAYMENT
NAME OF CONTRACTOR/SUBCONTRACTOR
ADDRESS
PHONE #
PAYROLL #
TAX I.D. #
CONTRACT REGISTRATION #
JOB CODE
WEEK ENDING DATE
PROJECT NAME & LOCATION
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
DAY AND DATE
SUPPLEMENTAL BENEFITS
LIST TRADE & CHECK
NAME
CLASSIFICATION
T
BASE
ADDRESS
JOURNEYMAN
I
RATE
PAID TO
TOTAL
TOTAL
RATE OF
TOTAL
TOTAL TAX &
NET PAY
M
GROSS PAY
APPRENTICE
PER
(Local # if Union is
BENEFITS
HOURS
PAY PER
BASE
OTHER
LAST FOUR DIGITS OF
E
(NYS DOL REGISTERED)
HOUR
checked)
PAID
HOUR
PAY
DEDUCTIONS
SOCIAL SECURITY NUMBER
HELPER
HOURS WORKED EACH DAY
RT
J
U
_____
Local#
A
E _________
H
O_________
OT
RT
J
U
_____
Local#
A
E _________
H
O_________
OT
RT
J
U
_____
Local#
A
E _________
H
O_________
OT
J
RT
U
_____
Local#
A
E _________
H
O_________
OT
J
RT
U
_____
Local#
A
E _________
H
O_________
OT
J
RT
U
_____
Local#
A
E _________
H
O_________
OT
J
RT
U
_____
Local#
A
E _________
H
O_________
OT
INSTRUCTIONS ON REVERSE SIDE
FALSIFICATION OF THIS STATEMENT IS A PUNISHABLE OFFENSE
This certified payroll has been prepared in accordance with the instructions contained on the reverse side of this form. I certify that the above information represents wages and supplemental
benefits paid to all persons employed by my firm for construction work on the above project during the period shown. I understand that falsification of this statement is a punishable offense.
___________________________
_____________________________________
________________________________
____________________________ ,20______
SIGNATURE
NAME (Print)
TITLE
DATE
THE CITY OF NEW YORK
OFFICE OF THE COMPTROLLER
BUREAU OF LABOR LAW
PAYROLL REPORT
NAME OF PRIME CONTRACTOR
AGENCY
TO BE SUBMITTED WITH REQUISITION FOR PAYMENT
NAME OF CONTRACTOR/SUBCONTRACTOR
ADDRESS
PHONE #
PAYROLL #
TAX I.D. #
CONTRACT REGISTRATION #
JOB CODE
WEEK ENDING DATE
PROJECT NAME & LOCATION
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
DAY AND DATE
SUPPLEMENTAL BENEFITS
LIST TRADE & CHECK
NAME
CLASSIFICATION
T
BASE
ADDRESS
JOURNEYMAN
I
RATE
PAID TO
TOTAL
TOTAL
RATE OF
TOTAL
TOTAL TAX &
NET PAY
M
GROSS PAY
APPRENTICE
PER
(Local # if Union is
BENEFITS
HOURS
PAY PER
BASE
OTHER
LAST FOUR DIGITS OF
E
(NYS DOL REGISTERED)
HOUR
checked)
PAID
HOUR
PAY
DEDUCTIONS
SOCIAL SECURITY NUMBER
HELPER
HOURS WORKED EACH DAY
RT
J
U
_____
Local#
A
E _________
H
O_________
OT
RT
J
U
_____
Local#
A
E _________
H
O_________
OT
RT
J
U
_____
Local#
A
E _________
H
O_________
OT
J
RT
U
_____
Local#
A
E _________
H
O_________
OT
J
RT
U
_____
Local#
A
E _________
H
O_________
OT
J
RT
U
_____
Local#
A
E _________
H
O_________
OT
J
RT
U
_____
Local#
A
E _________
H
O_________
OT
INSTRUCTIONS ON REVERSE SIDE
FALSIFICATION OF THIS STATEMENT IS A PUNISHABLE OFFENSE
This certified payroll has been prepared in accordance with the instructions contained on the reverse side of this form. I certify that the above information represents wages and supplemental
benefits paid to all persons employed by my firm for construction work on the above project during the period shown. I understand that falsification of this statement is a punishable offense.
___________________________
_____________________________________
________________________________
____________________________ ,20______
SIGNATURE
NAME (Print)
TITLE
DATE
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