*FRINGE BENEFITS EXPLANATION (P):
Bona fide benefits paid to approved plans, funds or programs, except those required by Federal or State
Law (unemployment tax, worker’s compensation, income taxes, etc.).
Please specify the type of benefits provided:
1) Medical or hospital care
4) Disability
2) Pension or retirement 5) Vacation, holiday
3) Life Insurance
6) Other (please specify)
CERTIFIED STATEMENT OF COMPLIANCE
For the week ending date of
,
I,
of , (hereafter known as
Employer) in my capacity as (title) do hereby certify and state:
Section A:
1. All persons employed on said project have been paid the full weekly wages earned by them during
the week in accordance with Connecticut General Statutes, section 31-53, as amended. Further, I
hereby certify and state the following:
a) The records submitted are true and accurate;
b) The rate of wages paid to each mechanic, laborer or workman and the amount of payment or
contributions paid or payable on behalf of each such person to any employee welfare fund, as
defined in Connecticut General Statutes, section 31-53 (h), are not less than the prevailing rate
of wages and the amount of payment or contributions paid or payable on behalf of each such
person to any employee welfare fund, as determined by the Labor Commissioner pursuant to
subsection Connecticut General Statutes, section 31-53 (d), and said wages and benefits are not
less than those which may also be required by contract;
c) The Employer has complied with all of the provisions in Connecticut General Statutes,
section 31-53 (and Section 31-54 if applicable for state highway construction);
d) Each such person is covered by a worker’s compensation insurance policy for the duration of
his employment which proof of coverage has been provided to the contracting agency;
e) The Employer does not receive kickbacks, which means any money, fee, commission, credit,
gift, gratuity, thing of value, or compensation of any kind which is provided directly or
indirectly, to any prime contractor, prime contractor employee, subcontractor, or subcontractor
employee for the purpose of improperly obtaining or rewarding favorable treatment in
connection with a prime contract or in connection with a prime contractor in connection with a
subcontractor relating to a prime contractor; and
f) The Employer is aware that filing a certified payroll which he knows to be false is a class D
felony for which the employer may be fined up to five thousand dollars, imprisoned for up to
five years or both.
2. OSHA~The employer shall affix a copy of the construction safety course, program or
training completion document to the certified payroll required to be submitted to the contracting
agency for this project on which such persons name first appears.
(Signature) (Title) Submitted on (Date)
***THIS IS A PUBLIC DOCUMENT***
***DO NOT INCLUDE SOCIAL SECURITY NUMBERS***
