Form LLC-25 at a glance
What it is: Weekly payroll certification for public works projects, LLC-25.
Notary: The notarization must be completed on first and last submissions only. All other information must be completed weekly.
A filled-in Form LLC-25 example: a contractor certifies one employee's week
How to fill out Form LLC-25, box by box
Contractor or Subcontractor and the project
Check one: Contractor or Subcontractor. All information must be completed.
Enter the ADDRESS under CONTRACTOR or under SUBCONTRACTOR.
Enter the PAYROLL NUMBER, the WEEK ENDING DATE and the PROJECT AND LOCATION.
Enter the PROJECT SERIAL # and the PROJECT #.
Employee name, hours and pay
For each employee, enter the EMPLOYEE NAME and the APPR. RATE (%).
Enter the WORK CLASSIFICATION.
Enter the DAY AND DATE and the HOURS WORKED EACH DAY.
Enter S- TIME and 0- TIME.
Enter the BASE HOURLY RATE.
Enter the TOTAL FRINGE BENEFITS (C=Cash) (FB=Contributions)*. The * after (FB=Contributions)* is *SEE REVERSE SIDE: FRINGE BENEFITS EXPLANATION (FB): Bona fide benefits contribution, except those required by Federal or State Law (unemployment tax, workers' compensation, income taxes, etc.). Enter the PAGE NUMBER and the number after OF.
Enter the GROSS PAY FOR PREVAILING RATE JOB(S), the TOTAL DEDUCTIONS and the CHECK #.
Benefits provided and contributions per hour
Please specify the type of benefits provided and contributions per hour: 1) Medical or hospital care, 2) Pension or retirement, 3) Life insurance, 4) Disability, 5) Vacation, holiday, 6) Other (please specify).
Certified statement of compliance
CERTIFIED STATEMENT OF COMPLIANCE 1. The undersigned, having executed a contract with (AWARDING AGENCY, CONTRACTOR OR SUBCONTRACTOR) for the construction of the identified project, acknowledges that: (a) The prevailing wage requirements and the predetermined rates are included in the aforesaid contract.
(b) Correction of any infractions of the aforesaid conditions is the contractor's or subcontractor's responsibility.
(c) It is the contractor's responsibility to include the Prevailing Wage requirements and the predetermined rates in any subcontract or lower tier subcontract for this project.
The undersigned certifies that: (a) Neither he nor his firm, nor any firm, corporation or partnership in which he or his firm has an interest is debarred by the Secretary of Labor and Industry pursuant to Section 11(e) of the PA Prevailing Wage Act, Act of August 15, 1961, P.L. 987 as amended, 43 P.S.§ 165-11(e).
(b) No part of this contract has been or will be subcontracted to any subcontractor if such subcontractor or any firm, corporation or partnership in which such subcontractor has an interest is debarred pursuant to the aforementioned statute.
Legal name, organization and owners
The undersigned certifies that: (a) the legal name and the business address of the contractor or subcontractor are:
(b) The undersigned is: a single proprietorship, a corporation organized in the state of ___, a partnership, other organization (describe).
(c) The name, title and address of the owner, partners or officers of the contractor/subcontractor are: NAME, TITLE, ADDRESS.
Date, signature and notarization
The willful falsification of any of the statements may subject the contractor to civil or criminal prosecution, provided in the PA Prevailing Wage Act of August 15, 1961, P.L. 987, as amended, August 9, 1963, 43 P.S. § 165.1 through 165.17.
Enter the (DATE), then the (SIGNATURE) and the (TITLE).
Taken, sworn and subscribed before me this _________ Day of ___, A.D., ___.
The notarization must be completed on first and last submissions only. All other information must be completed weekly.
Sources
[1] Form LLC-25 (REV 10-03), Weekly Payroll Certification for Public Works Projects, Pennsylvania Bureau of Labor Law Compliance Prevailing Wage Division (the Official source link on this page).
