DT1929 Weekly Payroll Report - DOA Home
|STATE OF WISCONSIN |[pic] |Mailing Address: P. O. Box 7866, Madison, WI 53707-7866 |
|DEPARTMENT OF ADMINISTRATION | |STREET ADDRESS: 101 E. WILSON STREET, 7TH FLOOR, MADISON, WI 53703 |
|Division of Facilities Development (DFD) | |PHONE: 608 / 266-2731; FAX: 608 / 267-2710 |
|DOA-4184 (R10/2012) | |[pic] |
|Adapted from: | | |
|US Dept. of Labor, Form WH-347 (29 CFR 5.5(1)(3)) | | |
CONTRACTOR WEEKLY PAYROLL REPORT
The weekly submittal of this form is required by 29 CFR Part 3. * Full name, address, and social security number must appear on the first payroll on which the employee’s name appears.
The social security number is collected for payroll purposes.
** Fringe benefit details MUST be reported on a supplementary page. *** Include private work. **** If Operating Engineer or Laborer, include class of equipment or skill level of laborer.
|Payroll # |Employer Name |State Project ID |Federal Project ID |County |Payroll Period Week |Sheet # |
| | | | | |Ending | |
| |Prime Contractor Subcontractor Hired By: | | | | | |
Enter information below on every individual that you employed on this project during the payroll report period.* |DAILY HOURS WORKED
S = Straight Time O = Overtime |TOTAL WEEKLY HOURS
WORKED |(A)
BASIC
HOURLY
RATE |(B) BENEFITS **
HOURLY RATE |(A) + (B)
TOTAL HOURLY
RATE |PROJECT
WAGES |FICA |FED WH |ST WH |OTHER
(Specify) |NET
PAID |CHECK
# | | | | | |FUND
PAYMENT |CASH
PAYMENT | |GROSS
WAGES | | | | | | | | | |SU |M |TU |W |TH |F |SA | | | | | | | | | | | | | |Name
Address
City, State, ZIP Code
S.S. #
Trade/Craft ****
Apprentice Yes No |REFERENCED PROJECT | | |
| | | | | | | | | | | |S | | | | | | | | |$ |$ |$ |$ | | | | | | | | | |O | | | | | | | | |$ |$ |$ |$ |$ | | | | | | | | |OTHER PROJECTS *** | | |$ |$ |$ |$ |$ |$ | | | |S | | | | | | | | | | | | | | | |O | | | | | | | | | | | | | | |Name
Address
City, State, ZIP Code
S.S. #
Trade/Craft ****
Apprentice Yes No |REFERENCED PROJECT | | | | | | | | | | | | | | |S | | | | | | | | |$ |$ |$ |$ | | | | | | | | | |O | | | | | | | | |$ |$ |$ |$ |$ | | | | | | | | |OTHER PROJECTS *** | | |$ |$ |$ |$ |$ |$ | | | |S | | | | | | | | | | | | | | | |O | | | | | | | | | | | | | | |Name
Address
City, State, ZIP Code
S.S. #
Trade/Craft ****
Apprentice Yes No |REFERENCED PROJECT | | | | | | | | | | | | | | |S | | | | | | | | |$ |$ |$ |$ | | | | | | | | | |O | | | | | | | | |$ |$ |$ |$ |$ | | | | | | | | |OTHER PROJECTS *** | | |$ |$ |$ |$ |$ |$ | | | |S | | | | | | | | | | | | | | | |O | | | | | | | | | | | | | | |Name
Address
City, State, ZIP Code
S.S. #
Trade/Craft ****
Apprentice Yes No |REFERENCED PROJECT | | | | | | | | | | | | | | |S | | | | | | | | |$ |$ |$ |$ | | | | | | | | | |O | | | | | | | | |$ |$ |$ |$ |$ | | | | | | | | |OTHER PROJECTS *** | | |$ |$ |$ |$ |$ |$ | | | |S | | | | | | | | | | | | | | | |O | | | | | | | | | | | | | | |Name
Address
City, State, ZIP Code
S.S. #
Trade/Craft ****
Apprentice Yes No |REFERENCED PROJECT | | | | | | | | | | | | | | |S | | | | | | | | |$ |$ |$ |$ | | | | | | | | | |O | | | | | | | | |$ |$ |$ |$ |$ | | | | | | | | |OTHER PROJECTS *** | | |$ |$ |$ |$ |$ |$ | | | |S | | | | | | | | | | | | | | | |O | | | | | | | | | | | | | | |
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