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Column 9 – Net Payment to Worker for All Work: Enter the actual dollar amount paid to the worker for all hours worked <br />across all projects (including non-DBRA covered projects) during the week. <br />Detailed instructions for completing the second page of Form WH-347 follow: <br />Project Name: Enter the name of the project on which you are reporting. <br />Project No. Or Contract No.: Enter the project or prime contract number associated with your contract assigned by the <br />relevant contracting agency (if available). <br />Payroll No.: Beginning with the number “1”, each weekly certified payroll that a contractor or subcontractor submits for a <br />project should be given a payroll number. Enter the appropriate payroll number. <br />Prime Contractor’s/Subcontractor’s Business Name: Enter the business’ legal name. <br />Project Location: Enter the complete address of the project, or, if there is no specific address, a description of the project <br />location, including, at a minimum, the county or counties and state in which the project is located. <br />Week Ending Date: Enter the workweek ending date for this pay period. <br />Certifying Official’s Name and Title: Print the name and official title of the contractor or subcontractor, or their agent who <br />paid or supervised the payment of the workers under the contract during the weekly time period covered by the form. <br />Statement of Compliance: While the “Statement of Compliance” need not be notarized, the statement (on page 2 of this <br />certified payroll form) is subject to the penalties provided by 18 U.S.C. § 1001, namely, a fine, possible imprisonment of <br />not more than 5 years, or both. Accordingly, the party signing this statement should have knowledge of the facts <br />represented as true. <br />If applicable, please “check” each of the 6 boxes certifying the accompanying statement as accurate. Boxes 1, 2, 3 and 6 <br />(i.e., the first three boxes and the last box) always must be checked to certify that the contractor or subcontractor <br />completing the form is in compliance with the DBRA. <br />Docusign Envelope ID: CF064D56-F89A-8651-8229-D168AFF8B909