MASSACHUSETTS WEEKLY CERTIFIED PAYROLL REPORT FOR
Company's Name: 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
(B+C+D+E) (A x F)
Employee Name & Complete Address
Employee is
OSHA 10
Certified (?) Work Classification:
Appr.
Rate
(%) Su. Mo. Tu. We. Th. Fr. Sa.
All Other
Hours
Hourly Base
Wage
(B)
Health &
Welfare
Insurance
(C')
ERISA
Pension Plan
(D)
Supp.
Unemp.
(E)
Total Hourly
Prev. Wage
(F)
Total Gross
Wages
Check No.
(H)
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 NOTE:
to the awarding authority. Failure to comply may result in the commencement of a criminal action or the issuance of a civil citation.
Date recieved by awarding authority
Page of
/ /
Hours
Worked
Project Gross
Wages
(G)
Project
Hours
(A)
