MASSACHUSETTS WEEKLY CERTIFIED PAYROLL REPORT FORM
[Pages:1]Company's Name:
MASSACHUSETTS WEEKLY CERTIFIED PAYROLL REPORT FORM
Address:
Phone No.:
Payroll No.:
Employer's Signature:
Title:
Contract No:
Tax Payer ID No.
Work Week Ending:
Awarding Authority's Name:
Public Works Project Name:
Public Works Project Location:
Min. Wage Rate Sheet No.
General / Prime Contractor's Name:
Subcontractor's Name:
"Employer" Hourly Fringe Benefit Contributions
Employee is
Appr.
Worked
OSHA 10
Rate
Employee Name & Complete Address Certified (?) Work Classification: (%)
Su.
Mo.
Tu.
We.
Th.
Hours
Fr.
Sa.
Project Hours
(A)
All Other Hours
Hourly Base Wage (B)
Health & Welfare Insurance
(C')
ERISA Pension Plan
(D)
Supp. Unemp.
(E)
(B+C+D+E)
Total Hourly Prev. Wage
(F)
(A x F) Project Gross
Wages (G)
Total Gross Wages
Check No. (H)
NOTE: Pursuant to MGL Ch. 149 s.27B, every contractor and subcontractor is required to submit a "true and accurate" copy of their weekly payroll records directly to the awarding authority. Failure to comply may result in the commencement of a criminal action or the issuance of a civil citation.
Page
of
Date recieved by awarding authority
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