SUBMIT form by
email: equalpayact@dol.nj.gov
IMPORTANT: For purposes of law,
you must also submit this form to
the appropriate public body or lessor.
Payroll Cercaon for Public Works Projects
for Contractor and Subcontractors Weekly and Final Cercaon
Name of Contractor or Subcontractor
Business Address
Project Locaon
Payroll No.
Week Ending Date
or Final Cercaon
NJ Department of Labor & Workforce Development
Project Name
Contract I.D. or Project I.D.
Contractor Registration #
Date Wages Due
& Paid
KEY W= White; B= Black or African American;
A= Asian; N= American Indian or Nave Alaskan;
I = Nave Hawaiian or Pacic Islander; M= 2 or More
MW-562 (6/18)
Check if addional sheets used
1. 5. 6. 9. 10.
JobTitle Sex
Race Ethnicity SU MO TU WE TH FR SA
M=Male
F=Female H=Hispanic
andAddress
journeyman,foreman e.g.,carpenter,mason,plumber
X=NonBinary N=NonHispanic
Hours ofPay Project Week FICA
S
O
O
S
S
O
O
S
S
O
O
S
S
O
O
S
S
O
2.Work
Hoursworkedeachday
DeductionsGrossAmt.Earned
or Overtime
StraightTime
3.Demographics
7.
8.
4.D ayandD ate
mm/dd mm/dd mm/dd mm/dd mm/dd mm/ddEmp loyeeName mm/dd
Total
Deductions
NetWages
Paidfor
Week
Total
Fringe
Benefit
Cost/Hour
e.g.,apprentice,
WorkClassification/
OccupationalCategory
SeeKey
Withholding
Tax
Total
Hourly Rate
This This
Date ___________
I, _________________________________ ___________________________________
(Name of signatory party) (Title)
do hereby state and cerfy:
(1) That I pay or supervise the payment of the persons employed by
_________________________________ on the ________________________________ ;
(Contractor or Subcontractor) (Project Name and Locaon)
that during the payroll period beginning on _____________, and ending on _____________,
(Date) (Date)
all persons employed on said project have been paid the full weekly wages earned, that no rebates
have been or will be made either directly or indirectly to or on behalf of said
_________________________________ from the full weekly wages earned by any
(Contractor or Subcontractor)
person and that no deducons have been made either directly or indirectly from the full wages
earned by any person, other than permissible deducons as dened in the New Jersey Prevailing
Wage Act, N.J.S.A. 34:11-56.25 et seq. and Regulaon N.J.A.C. 12:60 et seq. and the Payment of
Wages Law, N.J.S.A. 34:11-4.1 et seq.
(2) That any payrolls otherwise under this contract required to be submied for the above period are
correct and complete; that the wage rates for laborers or mechanics contained therein are not
less than the applicable wage rates contained in any wage determinaon incorporated into the
contract; that the classicaons set forth therein for each laborer or mechanic conform with the
work he performed.
(3) That any apprences employed in the above period are duly registered with the United States
Department of Labor, Bureau of Apprenceship and Training and enrolled in a cered
apprenceship program.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS OR PROGRAMS
In addion to the basic hourly wage rates paid to each laborer or mechanic listed in the
above referenced payroll, payments of fringe benets as listed in the contract have been or
will be made when due to appropriate programs for the benet of such employees, except as
noted in Secon 4(c) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
Each laborer or mechanic listed in the above referenced payroll has been paid as indicated
on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus
the amount of the required fringe benets as listed in the contract, except as noted in Secon
4(c) below.
(c) FRINGE BENEFITS
EXCEPTIONS (CRAFT)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
REMARKS
PLEASE SPECIFY THE TYPE OF BENEFIT PROVIDED AND NOTE THE TOTAL COST PER HOUR
IN BLOCK 10 ON PAGE 1 OF THIS FORM*
Medical or hospital coverage Dental coverage
Pension or Rerement Vacaon, Holidays
Sick days Life Insurance
Other (Explain) ______________________________________________________
* TO CALCULATE THE COST PER HOUR, DIVIDE 2,000 HOURS INTO THE BENEFIT COST PER
YEAR PER EMPLOYEE.
(5) N.J.S.A. 12:60-2.1 and 5.1 – The Public Works employers shall submit to the public body or lessor
a cered payroll record each pay period within 10 days of the payment of wages.
_________________________________ ___________________________________
NAME TITLE
_________________________________
SIGNATURE
THE FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR
SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. N.J.S.A. 34:11- 56.25 ET SEQ. AND
N.J.A.C. 12:60 ET SEQ. AND N.J.S.A. 34:11-4.1 ET SEQ.
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