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THE CITY OF NEW YORK OFFICE OF THE (City of New York)

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Country of origin: US
File type: PDF

U.S.A. forms for City of New York

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,20___________
THE CITY OF NEW YORK • OFFICE OF THE COMPTROLLER • BUREAU OF LABOR LAW
EMPLOYER NAME
EMPLOYER ADDRESS
EMPLOYER EMAIL ADDRESS
EMPLOYER PHONE #
EMPLOYER TAX I.D. #
PROJECT NAME
CERTIFIED PAYROLL REPORT
CHECK IF PROJECT LABOR
AGREEEMENT (PLA)
WEEK ENDING DATE
GROSS PAY
(THIS PROJECT)
WAGES
NAME OF PRIME CONTRACTOR, BUILDING OWNER OR UTILITY
CONTRACT REGISTRATION #
AGENCY
AGENCY PIN #
PROJECT OR BUILDING ADDRESS
(2)
(4)
(8)
(10)
NET PAY
HOURLY
CONTRIBUTIONS TO
BENEFIT FUNDS OR
INDIVIDUAL
ACCOUNTS
ALL
OTHER
BONA FIDE FRINGE BENEFITS
EMPLOYER
PROJECTED
ANNUAL COST
EMPLOYEE
PROJECTED
ANNUAL HOURS
ANNUALIZED
HOURLY RATE
BONA FIDE FRINGE BENEFITS
TOTAL GROSS PAY
(ALL WORK)
WITHHOLDINGS
&
DEDUCTIONS
HOURS WORKED EACH DAY
S
T
WORKER NAME
ADDRESS
LAST FOUR DIGITS OF SSN
TRADE CLASSIFICATION
UNION LOCAL #
JOURNEYPERSON OR
APPRENTICE
(NYS DOL REGISTERED)
T
I
M
E
THIS PROJECT, CONTRACT OR BUILDING
ALL WORK (PUBLIC AND PRIVATE)
DAY AND DATE
TOTAL
HOURS
HOURLY
RATE OF PAY
O
T
O
T
S
T
S
T
O
T
O
T
S
T
S
T
O
T
O
T
S
T
S
T
O
T
OFFICER OR PRINCIPAL OF EMPLOYER (Print Name)
TITLE
SIGNATURE
DATE
FALSIFICATION OF THIS STATEMENT IS A PUNISHABLE OFFENSE
This certified payroll report has been prepared in accordance with the instructions for this form. I certify that the above information represents the hours worked by, wages paid to and bona fide fringe benefits provided to all of the workers employed by the above named
employer on this project, contract or building during the period shown. I understand that falsification of this statement is a punishable offense.
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THE CITY OF NEW YORK OFFICE OF THE (City of New York)

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Completed 8 October 2020

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