"Weekly Payroll Certification for Covered Service Worker Contracts - for Food Service Contracts Only" - Connecticut

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

Form Details:

  • Released on April 21, 2005;
  • 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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PAYROLL CERTIFICATION FOR COVERED SERVICE WORKER CONTRACTS
WEEKLY PAYROLL CERTIFICATION
WEEK-ENDING DATE:
~FOR FOOD SERVICE CONTRACTS ONLY~
WEEKLY PAYROLL
TOTAL DEDUCTIONS
MALE/
WORK
DAY AND DATE
S-TIME
BASE HOURLY
TYPE OF FRINGE
GROSS PAY
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
BENEFIT PLAN
(see back)
FICA
WITH-
WITH-
OTHER
HOURS WORKED EACH DAY
O-TIME
CASH
HOLDING HOLDING
*** TIP CREDIT
1. $
$
S-Time:
$
2. $
Base Rate Per Hour
3. $
Gross Pay
4. $
$
O-Time:
$
5. $
Cash Fringe Per Hour
6. $
Tip Credit
1. $
$
S-Time:
$
2. $
Base Rate Per Hour
3. $
Gross Pay
4. $
$
O-Time:
$
5. $
Cash Fringe Per Hour
6. $
Tip Credit
1. $
$
S-Time:
$
2. $
Base Rate Per Hour
3. $
Gross Pay
4. $
$
O-Time:
$
5. $
6. $
Tip Credit
Cash Fringe Per Hour
1. $
$
S-Time:
2. $
$
Base Rate Per Hour
3. $
Gross Pay
4. $
$
O-Time:
$
5. $
6. $
Tip Credit
Cash Fringe Per Hour
1. $
$
S-Time:
$
2. $
Base Rate Per Hour
3. $
Gross Pay
O-Time:
4. $
$
$
Cash Fringe Per Hour 5. $
Tip Credit
1. $
$
S-Time:
$
2. $
Base Rate Per Hour
3. $
Gross Pay
4. $
$
O-Time:
$
5. $
Cash Fringe Per Hour
6. $
Tip Credit
*IF Required
PAGE NUMBER
OF
4/21/2005
NOTICE: THIS PAGE MUST BE ACCOMPANIED BY A COVER PAGE
PAYROLL CERTIFICATION FOR COVERED SERVICE WORKER CONTRACTS
WEEKLY PAYROLL CERTIFICATION
WEEK-ENDING DATE:
~FOR FOOD SERVICE CONTRACTS ONLY~
WEEKLY PAYROLL
TOTAL DEDUCTIONS
MALE/
WORK
DAY AND DATE
S-TIME
BASE HOURLY
TYPE OF FRINGE
GROSS PAY
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
BENEFIT PLAN
(see back)
FICA
WITH-
WITH-
OTHER
HOURS WORKED EACH DAY
O-TIME
CASH
HOLDING HOLDING
*** TIP CREDIT
1. $
$
S-Time:
$
2. $
Base Rate Per Hour
3. $
Gross Pay
4. $
$
O-Time:
$
5. $
Cash Fringe Per Hour
6. $
Tip Credit
1. $
$
S-Time:
$
2. $
Base Rate Per Hour
3. $
Gross Pay
4. $
$
O-Time:
$
5. $
Cash Fringe Per Hour
6. $
Tip Credit
1. $
$
S-Time:
$
2. $
Base Rate Per Hour
3. $
Gross Pay
4. $
$
O-Time:
$
5. $
6. $
Tip Credit
Cash Fringe Per Hour
1. $
$
S-Time:
2. $
$
Base Rate Per Hour
3. $
Gross Pay
4. $
$
O-Time:
$
5. $
6. $
Tip Credit
Cash Fringe Per Hour
1. $
$
S-Time:
$
2. $
Base Rate Per Hour
3. $
Gross Pay
O-Time:
4. $
$
$
Cash Fringe Per Hour 5. $
Tip Credit
1. $
$
S-Time:
$
2. $
Base Rate Per Hour
3. $
Gross Pay
4. $
$
O-Time:
$
5. $
Cash Fringe Per Hour
6. $
Tip Credit
*IF Required
PAGE NUMBER
OF
4/21/2005
NOTICE: THIS PAGE MUST BE ACCOMPANIED BY A COVER PAGE
*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/Disability
4) Vacation, Holiday
5) Tip Credit
6) Other (meals) 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***
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