700 010 69 Form – Fill Out and Use This PDF

STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION

WAGE AND HOUR RECO RD

Statement of Compliance:

700-010-69 Construction 02/11

DATE

I,

	(Name of signatory party)							(Title)
do hereby state:
(1) That I pay or supervise the payment of the persons employed by
				on the	;
(Contractor or Subcontractor)						(Building or work)
that during the payroll period commencing on the						day of
and ending the		day of						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

(Contractor or Subcontractor)

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 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended

(48 Stat. 948, 63 Stat. 108, 72 Stat. 967; 76 Stat. 357; 40 U.S.C. 3145), and described below:

(c) EXCEPTIONS

EXCEPTION (CRAFT)	EXPLANATION

REMARKS:

(2)That any payrolls otherwise under this contract required to be submitted 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 registered 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 PAID 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 listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in Section 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 benefits as listed in the contract, except as noted in Section 4(c) below:

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.

WH-347

Wage and Hour Record:

Contractor's Name

Payroll Number:

	(1)
	Employee Name
	and 4 Digit Identifier
	(9 digit SS and full address	(2)
	required on contracts Let
		Exemptions /
	prior to 1/19/09)
		Race &
		Gender

																						700-010-69
																					Construction
																						02/11
										Address
										Contract #							Project and Location
For Week Ending
										FIN #
		(4)		Day and Date						(6)		(7)		(8)		Deductions				(9)			(10)
									(5)
									Total	Pay Rate		Project								Net Wages			Total from
									Hours			Gross /	FICA	With-				Total from	Total	Paid for			Fringe Benefit
	Time											Weekly		holding				Deduction	Deductions
(3)																				week			Sheet
	Over											Gross		tax				Sheet					(attached)
Work Classif-	/																	(attached)
ication	Stright
	O								0.00	0.00		0.00
	S								0.00										$0.00	$	-
	O								0.00	0.00		0.00
	S								0.00										$0.00	$	-
	O								0.00	0.00		0.00
	S								0.00										$0.00	$	-
	O								0.00	0.00		0.00
	S								0.00										$0.00	$	-
	O								0.00	0.00		0.00
	S								0.00										$0.00	$	-
	O								0.00	0.00		0.00
	S								0.00										$0.00	$	-
	O								0.00	0.00		0.00
	S								0.00										$0.00	$	-
	O								0.00	0.00		0.00
	S								0.00										$0.00	$	-
	O								0.00	0.00		0.00
	S								0.00										$0.00	$	-
	O								0.00	0.00		0.00
	S								0.00										$0.00	$	-
	O								0.00	0.00		0.00
	S								0.00										$0.00	$	-

Contractor's Name

Payroll Number:

Address

For Week Ending

FIN #

Contract #

Project and Location

Fringe Benefits Record:

Contractor's Name

Payroll Number:

For Week Ending

FIN #

Address

700-010-69 Construction 02/11

Contract #

Project and Location

Employee Name (last, first)

Total

Fringe

Benefit

Amount

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00