[New] In accordance with Section 31-53b(a) of the C.G.S. each contractor shall provide a copy of the OSHA 10 Hour Construction Safety and Health Card for each employee, to be attached to the first
certified payroll on the project.
In accordance with Connecticut General Statutes, 31-53
PAYROLL CERTIFICATION FOR PUBLIC WORKS PROJECTS
Connecticut Department of Labor
Certified Payrolls with a statement of compliance Wage and Workplace Standards Division
shall be submitted monthly to the contracting agency.
WEEKLY PAYROLL 200 Folly Brook Blvd.
Wethersfield, CT 06109
CONTRACTOR NAME AND ADDRESS: SUBCONTRACTOR NAME & ADDRESS
WORKER'S COMPENSATION INSURANCE CARRIER
POLICY #
PAYROLL NUMBER
Week-Ending PROJECT NAME & ADDRESS
Date
EFFECTIVE DATE:
EXPIRATION DATE:
PERSON/WORKER,
APPR MALE/ WORK DAY AND DATE Total ST BASE HOURLY TYPE OF GROSS PAY TOTAL DEDUCTIONS GROSS PAY FOR
ADDRESS and SECTION
RATE FEMALE CLASSIFICATION S M T W TH F S Hours RATE FRINGE FOR ALL FEDERAL STATE THIS PREVAILING CHECK # AND
% AND BENEFITS WORK RATE JOB NET PAY
RACE* Trade License Type TOTAL FRINGE Per Hour PERFORMED LIST
& Number - OSHA Total BENEFIT PLAN 1 through 6 THIS WEEK FICA WITH- WITH- OTHER
10 Certification Number HOURS WORKED EACH DAY O/T Hours CASH (see back) HOLDING HOLDING
1. $
$ 2. $
Base Rate 3. $
4. $
$ 5. $
Cash Fringe 6. $
1. $
$ 2. $
Base Rate 3. $
4. $
$ 5. $
Cash Fringe 6. $
1. $
$ 2. $
Base Rate 3. $
4. $
$ 5. $
Cash Fringe 6. $
1. $
$
2. $
Base Rate 3. $
4. $
$ 5. $
Cash Fringe 6. $
12/9/2013 *IF REQUIRED
WWS-CP1 *SEE REVERSE SIDE
PAGE NUMBER
OF
OSHA 10 ~ATTACH CARD TO 1ST CERTIFIED PAYROLL
*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***
Weekly Payroll Certification For
PAYROLL CERTIFICATION FOR PUBLIC WORKS PROJECTS
Week-Ending Date:
Public Works Projects (Continued) Contractor or Subcontractor Business Name:
WEEKLY PAYROLL
PERSON/WORKER, APPR MALE/ WORK DAY AND DATE Total ST BASE HOURLY TYPE OF GROSS PAY TOTAL DEDUCTIONS GROSS PAY FOR
ADDRESS and SECTION RATE FEMALE CLASSIFICATION S M T W TH F S Hours RATE FRINGE FOR ALL WORK FEDERAL STATE THIS PREVAILING CHECK # AND
% AND BENEFITS
PERFORMED RATE JOB NET PAY
RACE*
Trade License Type TOTAL FRINGE Per Hour THIS WEEK
& Number - OSHA
Total BENEFIT PLAN 1 through 6 FICA WITH- WITH- OTHER
10 Certification Number HOURS WORKED EACH DAY O/T Hours CASH (see back) HOLDING HOLDING
1. $
$ 2. $
Base Rate 3. $
4. $
$ 5. $
Cash Fringe 6. $
1. $
$ 2. $
Base Rate 3. $
4. $
$ 5. $
Cash Fringe 6. $
1. $
$ 2. $
Base Rate 3. $
4. $
$ 5. $
Cash Fringe 6. $
1. $
$
2. $
Base Rate 3. $
4. $
$ 5. $
Cash Fringe 6. $
1. $
$ 2. $
Base Rate 3. $
4. $
$ 5. $
Cash Fringe 6. $
*IF REQUIRED
12/9/2013
WWS-CP2 NOTICE: THIS PAGE MUST BE ACCOMPANIED BY A COVER PAGE (FORM # WWS-CP1)
PAGE NUMBER OF
LIST
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome