Certified Transcript of Payroll
State of Illinois
Illinois Department of Labor
IL452CM02
Contractor and/or Subcontractor
Please place an “F” by the hourly rate for fringe benefits paid to a Fund jointly managed by one or more labor organizations or employers in accordance with the federal Labor
Management Relations Act (See instruction 4 for completing this form). In addition contractors/subcontractors who do not make contributions for covered fringe benefits to a fringe
benefit fund that is jointly managed and jointly governed by one or more labor organizations or employers in accordance with the federal Labor Management Relations Act must provide
the additional information set forth on the form on page 2 (see Instruction 5). Contractors/subcontractors who do not make contributions for fringe benefits on a per hour basis for each
hour worked must convert such contributions to an annualized per hour basis for purpose of reporting on this form in accordance with instruction 5. You must keep original records
showing start and end time each day.
Public Body Information
IDOL Case File Number: Payroll Start:
(Contract Number)
(Project Number)
(Project Location)
(Company Name)
(Contact Name)
(Street Address)
(City)
(Zipcode)
(Telephone Number)
(Public Body Name)
(Contact Name)
(Street Address)
(City)
(Zipcode)
(Telephone Number)
(State)
Report Hours for Each Day, Including Overtime Hours, List Hourly Prevailing Wage Rate and Hourly Fringe Benefits Allotments.
Worker Name, Address
Last Four of SSN & Telephone Number
* Hours worked each day
SUN MON TUE WED THR FRI SAT
Total Straight
Time Hours
Total OT
Hours
Hourly Wage
Rate
Per Pay Period
NetGross
OT Wage
Rate
PW
N
Labor Classification
Hourly Fringe Benefit:
Pension:
Health/Welfare:
Vacation:
Training:
(State)
PW
N
Labor Classification
Hourly Fringe Benefit:
Pension:
Health/Welfare:
Vacation:
Training:
PW
N
Labor Classification
Hourly Fringe Benefit:
Pension:
Health/Welfare:
Vacation:
Training:
*PW - Prevailing Hours Worked *N - Non Prevailing Hours Worked
Payroll End:
