Nj Payroll Certification – Fill Out and Use

NAME OF CONTRACTOR		OR SUBCONTRACTOR		ADDRESS
PAYROLL NO.	WEEK ENDING OR FINAL CERTIFICATION		PROJECT NAME AND LOCATION
	/	/

DATE WAGES DUE DATE WAGES PAID

CONTRACTOR REGISTRATION NUMBER

Overtime (OT) or

Straight time (ST)

3. DAY AND DATE

1.

2.

4.

5.

NAME AND ADDRESS

WORK

TOTAL

RATE

OF EMPLOYEE

CLASSIFICATION

HOURS

OF PAY

HOURS WORKED EACH DAY

OT

ST

OT

ST

OT

ST

OT

ST

OT

ST

OT

ST

OT

ST

Questions? Please contact the Division of Wage and Hour Compliance at (609) 292-2259 or (609) 292-2283.

	6.
GROSS					7.
AMOUNT					DEDUCTIONS
EARNED
This		Total for		With-				Total
Project			FICA	holding				Deduc-
		Week
Only				Tax				tions

8.9.

NET Total

WAGES Fringe

PAID FOR Benefit

WEEK Cost/Hr.

Date

I,

(Name of signatory party)

(Title)

do hereby state and certify:

(1) That I pay or supervise the payment of the persons employed by

on the

;

(Contractor or Subcontractor)

(Project Name and Location)

that during the payroll period beginning on

, and ending on

, all persons employed

(Date)

(Date)

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

(Contractor or Subcontractor)

from the full 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 the New Jersey Prevailing Wage Act, N.J.S.A. 34:11-56.25 et seq. and Regulation N.J.A.C. 12:60 et seq. and the Payment of Wages Law, N.J.S.A. 34:11-4.1 et seq.

(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 with the United States Department of Labor, Bureau of Apprenticeship and Training and enrolled in a certified apprenticeship program.

(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 when due 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.

(c)FRINGE BENEFITS

EXCEPTIONS (CRAFT)

REMARKS

PLEASE SPECIFY THE TYPE OF BENEFIT PROVIDED AND NOTE THE TOTAL COST PER HOUR IN BLOCK 9 ON THE REVERSE SIDE*

1) Medical or hospital coverage

2) Dental coverage

3) Pension or Retirement

4) Vacation, Holidays

5) Sick days

6) Life Insurance

7) Other (Explain)

*TO CALCULATE THE COST PER HOUR, DIVIDE 2,000 HOURS INTO THE BENEFIT COST PER YEAR PER EMPLOYEE.

(5)N.J.S.A. 12:60-2.1 and 6.1 – The Public Works employers shall submit to the public body or lessor a certified payroll record each pay period within 10 days of the payment of wages.

NAME AND TITLE

SIGNATURE

THE FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. N.J.S.A. 34:11- 56.25 ET SEQ. AND N.J.A.C. 12:60 ET SEQ. AND N.J.S.A. 34:11-4.1 ET SEQ.