WEEKLY PAYROLL RECORDS REPORT & STATEMENT OF COMPLIANCE. In accordance with Massachusetts General Law c149, section 27B, a true and accurate record must be kept of
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MASSACHUSETTS WEEKLY CERTIFIED PAYROLL REPORT FORM Company's Name:
Address:
Phone No.:
Payroll No.:
Employer's Signature:
Title:
Contract No:
Awarding Authority's Name:
Public Works Project Name:
Public Works Project Location:
General / Prime Contractor's Name:
Subcontractor's Name:
Tax Payer ID No.
Work Week Ending:
Min. Wage Rate Sheet No.
"Employer" Hourly Fringe Benefit Contributions
(B+C+D+E)
Hours
Employee Name & Complete Address
Employee is OSHA 10 Certified (?)
Work Classification:
Appr. Rate (%)
Worked Su.
Mo.
Tu.
We.
Th.
Fr.
Sa.
Project Hours (A) All Other Hours
Hourly Base Wage (B)
Health & Welfare Insurance (C')
ERISA Pension Plan (D)
Supp. Unemp. (E)
Total Hourly Prev. Wage (F)
NOTE: Pursuant to MGL Ch. 149 s.27B, every contractor and subcontractor is required to submit a "true and accurate" copy of their weekly payroll records directly to the awarding authority. Failure to comply may result in the commencement of a criminal action or the issuance of a civil citation. Date recieved by awarding authority Page
