Massachusetts Weekly Certified Payroll Report Form

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
of
/
/
(A x F)
Project Gross
Wages
(G)
Total Gross
Wages
Check No.
(H)