Date
I,
(Name of Signatory Party) (Title)
do hereby state:
(1) That I pay or supervise the payment of the persons employed by
o
n
t
h
e
(Contractor or Subcontractor)
; that during the payroll period commencing on the
(Building or Work)
day of , , and ending the day of , ,
all persons employed on said project have been paid t
he full weekly wages earned, that no rebates have
been or will be made either directly or indirectly to or on behalf of s
aid
from the full
(Contractor or Subcontractor)
weekly wages earned by any person and that no deductions have been made either directly or indirectly
from the full wages earned by any person, other than permissible deductions as defined in Regulations, Part
3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948,
63 Stat. 108, 72 Stat. 967; 76 St
at. 357; 40 U.S.C. § 3145), and described below:
(2) That
any payrolls ot
herwise under this contract required to be subm
itted 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 determination incorporated into the contract; that the classifications
set forth therein for each laborer or mechanic conform with the work he performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship
program regis
tered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and
Training, United States Department of Labor, or if no such recognized agency exists in a State, are registered
with the Bureau of Apprenticeship and Training, United States Department of Labor.
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAI
D TO APPROVED PLANS, FUNDS, OR PROGRAMS
−
in addition to the basic hourly wage rates paid to each laborer or mechanic listed in
the above referenced payroll, payments of fringe benefits as list
ed in the contract
have b
een or will be made to appropriate programs for the benefit of such employees,
e
xcept as noted in section 4(c)
below.
(b) WHERE FRINGE BENEFITS AR
E 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 benefits as listed
in the contract, except as noted in section 4(c) below.
(c) E
XCEPTIONS
REMARKS:
EXCEPTION (CRAFT)
EXPLANATION
NAME AND TITLE SIGNATURE
THE WILLFUL FALSIFICATION OF ANY
OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR
SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE
31 OF THE UNITED STATES CODE.
