Certified Payroll Form for Davis Bacon Act

CERTIFIED PAYROLL REPORT (DAVIS-BACON ACT COMPLIANCE)

Document Control

• Effective Date: [Insert Date]
• Version: 2024.1.0-DBA
• Jurisdiction: U.S. Department of Labor (DOL) / 29 CFR Part 5
• Scope: Federal Prevailing Wage Contract Compliance

1. OFFICIAL NOTICE & COMPLIANCE DISCLAIMER

LEGAL NOTICE: This document constitutes a certified payroll record required under the Davis-Bacon and Related Acts (DBRA), 40 U.S.C. § 3141 et seq., and 29 CFR Part 3 and 5. Failure to submit accurate, truthful, and complete records may subject the contractor or subcontractor to civil and criminal penalties, including debarment from federal contracts. Information provided herein is subject to verification by the DOL or applicable contracting agency.

2. CONTRACTOR & PROJECT DATA

• Contractor Name: [Full Legal Business Name]
• Address: [Street Address, City, State, Zip]
• Project Name: [Name of Federal Project]
• Contract Number: [Prime Contract Number]
• Payroll Week Ending: [Date] | Payroll Number: [#]

3. OPERATIVE CLAUSES & TERMS

1. PREVAILING WAGE ADHERENCE: The Contractor certifies that all laborers and mechanics employed on this project have been paid the prevailing wage rates and fringe benefits as specified in the applicable Wage Determination Decision ([Insert Wage Decision Number]).
2. PAYMENT FREQUENCY: All employees are paid on a weekly basis, consistent with the requirements of 29 CFR § 5.5(a)(1).
3. FRINGE BENEFIT VERIFICATION: Where fringe benefits are paid to approved plans, funds, or programs, the Contractor maintains the records required by 29 CFR § 5.5(a)(1)(iv). Any payments made in cash in lieu of fringe benefits are accurately recorded in the "Rate of Pay" column.
4. DEDUCTIONS: All payroll deductions (e.g., FICA, withholding, authorized voluntary deductions) are in compliance with the Copeland "Anti-Kickback" Act (40 U.S.C. § 3145).
5. RECORD RETENTION: The Contractor shall maintain these records and supporting documentation for a period of three (3) years after the completion of the project, available for inspection by authorized representatives of the contracting agency or the DOL.

4. EMPLOYEE DATA TABLE (SUMMARY)

5. EXECUTION & STATEMENT OF COMPLIANCE

I, [Authorized Agent Name], acting as [Title] for [Company Name], do hereby certify that the information provided is accurate and complete. I further certify that: (1) no kickbacks of wages were made, and (2) each laborer or mechanic has been paid the full weekly wages earned, without rebate.

• Signature: __________________________ Date: [Date]
• Printed Name: [Full Legal Name]
• Title: [Job Title]

6. STEP-BY-STEP EXECUTION GUIDE

1. Verify Wage Determination: Ensure the [Wage Decision Number] listed matches the current version published on sam.gov at the time of contract solicitation.
2. Audit Deductions: Confirm that any non-statutory payroll deductions (e.g., tool rentals, equipment, uniforms) have been explicitly authorized in writing by the employee and are not violating the Copeland Act.
3. Submission Workflow: Submit this report to the Prime Contractor or the Contracting Officer within seven (7) days of the regular payment date for the payroll period.
4. Digital Archiving: Generate a PDF/A copy of the signed document, timestamped with the delivery confirmation receipt, and store it in the project compliance folder for a minimum of 36 months post-project closeout.