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
Certified (?) Work Classification:
(%) Su. Mo. Tu. We. Th. Fr. Sa.
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