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Contractors Certified Payroll Form

NAME OF CONTRACTOR
OR SUBCONTRACTOR:

ADDRESS:

PAYROLL NO.:

FOR WEEK ENDING:

PROJECT AND LOCATION:

PROJECT OR CONTRACT NO:

(1) Name, Address, and Last four (4) digits Social Security Number of Employee

(2) Work Classification

(3) Day and Date - hours worked each day

(4) Total Hours

(5) Rate of Pay

(6) Gross Amount Earned

(7) Deductions - FICA, With Holding Tax, Other, Total Deductions

(8) Net Wages Paid For Week