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U.S. Department of Labor PAYROLL
<br />Employment Standards Administration (For Contractor's Optional Use; See Instructions at www.dol.govlase/whd/forms/wh347instr.htm)
<br />Wage and Hour Division
<br />Persons are not required to respond to the collection o7 information unless It displays a currently valid OM9 control number.
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<br />t?:S. SVage and Hain 1JtviaitaD
<br />Rev. Dec. 200R
<br />IVNMC Vr l:VnllRHl:WRu .UR JUtfcUNIRAGtORu ADDRESS OMB No.: 1215-014E
<br />6rpfres: 12/31/2011
<br />PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECTOR CONTRACT NO.
<br />(1) ~(2) (3) (4)DAY AND GATE (5) (8) (7).
<br />8
<br />(9)
<br /> ~
<br />~ ai
<br />~ (
<br />)
<br />DEDUCTIONS
<br />NAME AND INDIVIDUAL IDENTIFYING NUMBER
<br />
<br />(e.g., LAST FOUR DIGITS OF SOCIAL SECURITY ~ ~
<br />
<br />WORK
<br />
<br />o
<br />
<br />TOTAL
<br />
<br />RATE GROSS
<br />
<br />AMOUNT V,tiTt{_
<br />
<br />HOLDING
<br />
<br />T
<br />TAL NET
<br />WAGES
<br />
<br />NUMBER OF WORKER
<br />z 3
<br />CLASSIFICATION
<br />HOUR
<br />S WO
<br />RKED EAC
<br />H DA
<br />Y
<br />HOURS
<br />OF PAY
<br />EARNED
<br />FICA
<br />TAX
<br />OTHER O
<br />DEDUCTIONS PAID
<br />FOR WEEK
<br /> 0
<br /> s
<br /> 0
<br /> s
<br /> D
<br /> s
<br /> 0
<br /> s
<br /> 0
<br /> s
<br /> 0
<br /> s
<br /> 0
<br /> s
<br /> 0
<br /> s
<br />...._- --_.,._._.. _.. _.... _.. _ ..._ _,.._.._., ..._ ..._..--•-•+ •-. --•-•__ __..-__._._ ...... ,,.........,.a...,,v ,,e.,...,,,,,,d ..,,,,, ,,,, , e„e,a„y ,«,~,,;e~ ~, aoew,w cuwaacuon canrraras ro responc ro ma mrormanan conecnon Wntained in 29 C.F.R. §§ 3.3, 5.5(a). Tha Copeland Act
<br />(40 U.S.C. § 3145) contrectore end subcontractors performing work on Federally financed or assisted construction contracts to "furnish weakly a statement with respect to the wages paid each employee during the preceding week." U.S. Department of Labor (DOL) regulatlona et
<br />29 C.F.R. § 5.5(a)(3)(II) roquire contreGOre to submk weekly a wpy of all payrolls to the Federal agency cantreding for or financing the construction protect, accompanied by a signed "Statement of Compliance" indicating that the payrolls ere correct and complete end that each laborer
<br />or mechanic has been paid not lase than the proper Davie-Bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving this infonnadon review the information to determine that employees have received legalty requ(red wages and fringe benefits.
<br />Publle Burden Statement
<br />We estimate that Is will take an average of 55 minutes to romplete this collection, Including time for reviewing Inatruc8ons, searching existing data sources, gathedng and malntaining the data needed, and completing end reviewing the cellectlon of Informa0on. If you have
<br />any comments regarding these es8mates or any other aspect of this collection, Including suggestions for reducing this burden, send them to the Administrator, Wage and Hour DMalon, ESA,11.8, Department of Labor, Room 53502, 200 ConsBtutlon Avenue, N.W.
<br />Waahington, D.C.20210
<br />(over)
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