Certified Payroll Form - Minnesota

This Minnesota-specific printable "Certified Payroll Form" is a part of the legal paperwork issued by the Minnesota Department of Labor and Industry.

Download the up-to-date PDF by clicking the link below and mail it as per the guidelines provided by the department.

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Minnesota Department of Labor and Industry Certified Payroll Form
This is a two part form consisting of Part 1 - Prevailing Wage Payroll Information listed below and the accompany Part 2 - Statement of Compliance. The contractor and
subcontractor(s) shall furnish these completed forms every two weeks to the contracting authority. Copies of the Prevailing Wage Payroll Information form and the Statement of
Compliance form are available at DLI.MN.GOV/LS/PrevWage.asp
All payrolls must be certified by attaching to each report a completed and executed Statement of Compliance.
Name of Contractor or
Prime Contractor Name
Subcontractor
Address & Telephone Number
Address & Telephone Number
Pay Period End Date
Project Name and Location
Contract Purchase Order Number
Payroll #
2
5
Day of Week & Date (xx/xx)
10
1
3
4
6
7
8
9
11
Labor Code and
Gross
Su
M
T
W
Th
F
S
Gross
-----------------
Total
Hrly
Amt
Employee Name, Address, &
Other
Other
# of
OT
Amt.
Identifying Number
-
Hrs
Rates
Earned
Fed
State
Total
Total Net
(Specify)
(Specify)
Exemp-
&
Earned
FICA
(DO NOT provide Social Security
This
of
Tax
Tax
Deductions
Wages Paid
Classification
This
tions
ST
This
No.)
Title
Job
Pay
Pay
Hours Worked Each Day
Job
Period
OT
ST
OT
ST
OT
ST
OT
ST
OT
ST
OT
ST
OT
ST
OT
ST
*Pursuant to the Minnesota Government Data Practices Act, all of the data provided hereunder is public data, which is available to anyone upon request. DO NOT provide any confidential data such as
social security numbers, in part or whole, on this form. This data is collected pursuant to Minnesota Stat. §177.30 Sub. 4 and 177.43 Sub. 3. If you have questions regarding the Prevailing Wage Laws,
contact the Minnesota Department of Labor & Industry, 443 Lafayette Road Nl, St. Paul, MN 55155, Phone (651) 284-5091 or 1-800-DIAL-DLI (1-800-342-53584), TTY (651) 297-4198. The willful
falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal prosecution under state and/or federal law.
Minnesota Department of Labor and Industry Certified Payroll Form
This is a two part form consisting of Part 1 - Prevailing Wage Payroll Information listed below and the accompany Part 2 - Statement of Compliance. The contractor and
subcontractor(s) shall furnish these completed forms every two weeks to the contracting authority. Copies of the Prevailing Wage Payroll Information form and the Statement of
Compliance form are available at DLI.MN.GOV/LS/PrevWage.asp
All payrolls must be certified by attaching to each report a completed and executed Statement of Compliance.
Name of Contractor or
Prime Contractor Name
Subcontractor
Address & Telephone Number
Address & Telephone Number
Pay Period End Date
Project Name and Location
Contract Purchase Order Number
Payroll #
2
5
Day of Week & Date (xx/xx)
10
1
3
4
6
7
8
9
11
Labor Code and
Gross
Su
M
T
W
Th
F
S
Gross
-----------------
Total
Hrly
Amt
Employee Name, Address, &
Other
Other
# of
OT
Amt.
Identifying Number
-
Hrs
Rates
Earned
Fed
State
Total
Total Net
(Specify)
(Specify)
Exemp-
&
Earned
FICA
(DO NOT provide Social Security
This
of
Tax
Tax
Deductions
Wages Paid
Classification
This
tions
ST
This
No.)
Title
Job
Pay
Pay
Hours Worked Each Day
Job
Period
OT
ST
OT
ST
OT
ST
OT
ST
OT
ST
OT
ST
OT
ST
OT
ST
*Pursuant to the Minnesota Government Data Practices Act, all of the data provided hereunder is public data, which is available to anyone upon request. DO NOT provide any confidential data such as
social security numbers, in part or whole, on this form. This data is collected pursuant to Minnesota Stat. §177.30 Sub. 4 and 177.43 Sub. 3. If you have questions regarding the Prevailing Wage Laws,
contact the Minnesota Department of Labor & Industry, 443 Lafayette Road Nl, St. Paul, MN 55155, Phone (651) 284-5091 or 1-800-DIAL-DLI (1-800-342-53584), TTY (651) 297-4198. The willful
falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal prosecution under state and/or federal law.
MINNESOTA DEPARTMENT OF LABOR & INDUSTRY
Part 2 Statement of Compliance
REPORT NUMBER
STATE PROJECT NAME AND LOCATION
DATE
CONTACTING AUTHORITY
PROJECT
GENERAL CONTRACTOR
CONTRACTOR/SUBCONTRACTOR
PHONE NUMBER
CONTRACT PURCHASE ORDER NUMBER
ADDRESS
CITY/STATE
ZIP
TYPE OF WORK
(Complete as described on solicitation documents.)
STATEMENT WITH RESPECT TO COMPLIANCE AND WAGES PAID
I,
do hereby state:
(Name of signatory party)
(Title- Owner or Officer)
(1) That I pay or supervise the payment of the persons employed by
on said Contract; that during the payroll period commencing on the
day of
of the year
, and
ending the
day of
of the year
, there were
employees performing work on said
Contract. That all persons performing work under said Contract are listed on the payroll and have been paid the full prevailing
wages for all hours worked under said Contract, that no rebates and or deductions have or will be made either directly or
indirectly to or on behalf of said
(Contractor or Subcontractor)
from the full wages earned by any person, other than permissible deductions as defined in Minnesota Statutes 177.24, Subdivision
4, 181.06, and 181.79, issued by the Minnesota Commissioner of Labor and Industry and described below:
DESCRIBE LEGAL DEDUCTIONS
(2) That the payroll submitted under said Contract is complete and accurate; that the wage rate(s) of the laborer(s), mechanic(s), and
worker(s) performing work under said Contract is (are) paid according to the wage determination(s) and labor provisions
incorporated in said Contract and according to applicable laws; that wages paid to laborer(s) mechanic(s), and worker(s) performing
work under said Contract is at least the prevailing wage rate for the most similar classification of labor performed as defined under
applicable law; and that the laborer(s), mechanic(s), and worker(s) performing work under said Contract is (are) paid for all hours
in excess of the prevailing hours at a rate of at least one and one-halftimes the applicable base rate of pay.
(3) That any apprentices employed during said payroll period are duly registered in a bona fide apprenticeship program registered with
the Minnesota Department of Labor and Industry, or are registered with the Bureau of Apprenticeship and Training; United States
Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO ANY APPROVED PLANS, FUNDS, OR PROGRAMS
In addition to the basic hourly wage rates paid to each laborer, worker or mechanic listed on said payroll, payments
to current, bona fide fringe benefit programs as set forth in paragraph 4(d), have been or will be made to the
program's administrators as set forth in paragraph 4(e) for the benefit of said employees, except as noted in Section
4(c).
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH TO ALL EMPLOYEES
Each laborer, worker, or mechanic listed on said payroll has been paid, as indicated on the payroll, an amount not
less than the sum of the applicable basic rate plus the fringe rate as listed in the appropriate wage determination
incorporated into said Contract.
NOTE- FRINGE BENEFIT SECTIONS C, D, E AND SIGNATURE BLOCK ARE ON NEXT PAGE
(c) EXCEPTIONS
EMPLOYEE NAME
CLASSIFICATION/OCCUPATION
EXPLANATION
DOLLARS CONTRIBUTED PER HOUR
(d) BENEFIT PROGRAM INFORMATION in
(Must be completed if 4(a) is checked.)
A
PPRENTI-
PROGRAM TITLE, CLASSIFICATION TITLE, OR
HEALTH/
VACATION/
PENSION
OTHER
CESHIP
INDIVIDUAL EMPLOYEES
WELFARE
HOLIDAY
INCLUDE TITLE
TRAINING
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
(e) BENEFIT PROGRAM INFORMATION (Must be completed if 4(a) is checked.)
NAME
&
ADDRESS OF FRINGE BENEFIT
BENEFIT ACCOUNT
THIRD PARTY TRUSTEE
TELEPHONE NUMBER
FUND, PLAN, OR PROGRAM
NUMBER
AND/OR CONTACT PERSON
ADMINISTRATOR
The willful falsification of any of the above statements may subject the contractor or subcontractor to
civil or criminal prosecution under federal and/or state law.
NAME AND TITLE OF OWNER OR OFFICER
SIGNATURE
As a representative of the contractor submitting the payroll identified above, I hereby certify that the payroll is true and correct to
the best of my knowledge.
NOTE: For information regarding this form, submission of payroll records, or copies of the laws stated above,
contact the Minnesota Department of Labor and Industry, 443 Lafayette Road N., St. Paul, MN 55155,
Phone: (651) 284-5091 or 1-800-DIAL-DLI (1-800-342-5354), TTY: (651) 297-4198.

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