THE CITY OF NEW YORK - New York City Comptroller

EMPLOYER NAME EMPLOYER ADDRESS

THE CITY OF NEW YORK ? OFFICE OF THE COMPTROLLER ? BUREAU OF LABOR LAW

CERTIFIED PAYROLL REPORT

EMPLOYER EMAIL ADDRESS

EMPLOYER PHONE #

EMPLOYER TAX I.D. #

CHECK IF PROJECT LABOR PAYROLL # AGREEEMENT (PLA)

PROJECT NAME

WEEK ENDING DATE

NAME OF PRIME CONTRACTOR, BUILDING OWNER OR UTILITY

CONTRACT REGISTRATION #

AGENCY

AGENCY PIN #

PROJECT OR BUILDING ADDRESS

(1)

WORKER NAME ADDRESS

LAST FOUR DIGITS OF SSN

(2)

(3)

TRADE CLASSIFICATION

UNION LOCAL #

T I

JOURNEYPERSON OR

M E

APPRENTICE

(NYS DOL REGISTERED)

S T

(4)

(5)

(6)

(7)

THIS PROJECT, CONTRACT OR BUILDING

DAY AND DATE

TOTAL

HOURLY

HOURS RATE OF PAY

GROSS PAY (THIS PROJECT)

HOURS WORKED EACH DAY

(8)

WAGES

TOTAL GROSS PAY (ALL WORK)

W ITHHOLDINGS &

DEDUCTIONS

(9)

(10)

ALL WORK (PUBLIC AND PRIVATE)

BONA FIDE FRINGE BENEFITS

NET PAY

HOURLY CONTRIBUTIONS TO BENEFIT FUNDS OR

INDIVIDUAL ACCOUNTS

ALL OTHER BONA FIDE FRINGE BENEFITS

EMPLOYER PROJECTED ANNUAL COST

EMPLOYEE PROJECTED ANNUAL HOURS

ANNUALIZED HOURLY RATE

O

T

J

A

S T

O

T

J

A

S T

O

T

J

A

S T

O

T

J

A

S T

O

T

J

A

S T

O

T

J

A

S T

O

T

J

A

FALSIFICATION OF THIS STATEMENT IS A PUNISHABLE OFFENSE

This certified payroll report has been prepared in accordance with the instructions for this form. I certify that the above information represents the hours worked by, wages paid to and bona fide fringe benefits provided to all of the workers employed by the above named employer on this project, contract or building during the period shown. I understand that falsification of this statement is a punishable offense.

OFFICER OR PRINCIPAL OF EMPLOYER (Print Name)

TITLE

SIGNATURE

DATE

,20___________

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