Contractor's/Subcontractor's Payroll Report (page 1 of 2)
PAYROLL REPORT
(TO BE SUBMITTED WITH REQUISITION FOR PAYMENT)
| NAME OF | | | | ADDRESS |
|CONTRACTOR/SUBCONTRA| | | | |
|CTOR | | | | |
(1) | (2) LIST TRADE | (3) | (4) | | |DAY AND DATE | | | | (5) | (6) | (7) |SUPPLEMENTAL BENEFITS | (11) | (12) | (13) | |NAME, |& CIRCLE WORK | | | | | | | | |TOTAL |BASE |TOTAL | | (9) ( | | | | | |ADDRESS, |CLASSIF: |TIME | | | | | | | |HOURS |RATE OF |BASE | (8) |PAID TO | (10) |GROSS |TOTAL TAX |NET | |SOCIAL SECURITY No. |JOURNEYPERSON | | | | | | | | | |PAY PER |PAY |RATE |(Local # if |TOTAL |PAY |& OTHER |PAY | | |APPRENTICE | | | | | | | | | |HOUR | |PER |Union is
|PAID | |DEDUCTIONS | | | |HELPER | | | | |HOURS WORKED EACH DAY | | | | | | |HOUR |Checked) | | | | | | | | | | | | | | | | | | | | | | | | | | |J |RT | | | | | | | | | | | |U Local No. | | | | | | | | | | | | | | | | | | | | | | | | | | |A | | | | | | | | | | | | |E | | | | | | | | | | | | | | | | | | | | | | | | | | |H |OT | | | | | | | | | | | |O | | | | | | | | | | | | | | | | | | | | | | | | | | |J |RT | | | | | | | | | | | |U Local No. | | | | | | | | | | | | | | | | | | | | | | | | | | |A | | | | | | | | | | | | |E | | | | | | | | | | | | | | | | | | | | | | | | | | |H |OT | | | | | | | | | | | |O | | | | | | | | | | | | | | | | | | | | | | | | | | |J |RT | | | | | | | | | | | |U Local No. | | | | | | | | | | | | | | | | | | | | | | | | | | |A | | | | | | | | | | | | |E | | | | | | | | | | | | | | | | | | | | | | | | | | |H |OT | | | | | | | | | | | |O | | | | | | | | | | | | | | | | | | | | | | | | | | |J |RT | | | | | | | | | | | |U Local No. | | | | | | | | | | | | | | | | | | | | | | | | | | |A | | | | | | | | | | | | |E | | | | | | | | | | | | | | | | | | | | | | | | | | |H |OT | | | | | | | | | | | |O | | | | | | | | | | | | | | | | | | | | | | | | | | |J |RT | | | | | | | | | | | |U Local No. | | | | | | | | | | | | | | | | | | | | | | | | | | |A | | | | | | | | | | | | |E | | | | | | | | | | | | | | | | | | | | | | | | | | |H |OT | | | | | | | | | | | |O | | | | | | | | | | | | | | | | | | | | | | | | | | |J |RT | | | | | | | | | | | |U Local No. | | | | | | | | | | | | | | | | | | | | | | | | | | |A | | | | | | | | | | | | |E | | | | | | | | | | | | | | | | | | | | | | | | | | |H |OT | | | | | | | | | | | |O | | | | | | | | | | | | | | | | | | | | | | | | | | |J |RT | | | | | | | | | | | |U Local No. | | | | | | | | | | | | | | | | | | | | | | | | | | |A | | | | | | | | | | | | |E | | | | | | | | | | | | | | | | | | | | | | | | | | |H |OT | | | | | | | | | | | |O | | | | | | | | | | | | | | | | | | | | | | | | | | |J |RT | | | | | | | | | | | |U Local No. | | | | | | | | | | | | | | | | | | | | | | | | | | |A | | | | | | | | | | | | |E | | | | | | | | | | | | | | | | | | | | | | | | | | |H |OT | | | | | | | | | | | |O | | | | | | | | | | | | | | | | | | | | | | | | | | |J |RT | | | | | | | | | | | |U Local No. | | | | | | | | | | | | | | | | | | | | | | | | | | |A | | | | | | | | | | | | |E | | | | | | | | | | | | | | | | | | | | | | | | | | |H |OT | | | | | | | | | | | |O | | | | | | | | | | | | | | | | | | | | | | | | | | |J |RT | | | | | | | | | | | |U Local No. | | | | | | | | | | | | | | | | | | | | | | | | | | |A | | | | | | | | | | | | |E | | | | | | | | | | | | | | | | | | | | | | | | | | |H |OT | | | | | | | | | | | |O | | | | | |(INSTRUCTIONS ON REVERSE SIDE)
FALSIFICATION OF STATEMENT IS A PUNISHABLE OFFENSE
I hereby certify that the above information represents wages and supplemental benefits paid to all persons employed by my firm for construction work upon the above project during the period shown.
I understand that the Agency relies upon the information as being complete and accurate in making payments to the undersigned.
___________________________________________ ___________________________________________ ______________________________________ _____________________________
SIGNATURE NAME (Print) TITLE DATE
-----------------------
AGENCY
DEPT. OF DESIGN AND CONSTRUCTION
THE CITY OF NEW YORK
OFFICE OF THE COMPTROLLER
DIVISION OF LABOR LAW
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