Certified Payroll Form for Prevailing Wage

CERTIFIED PAYROLL REPORT (PREVAILING WAGE COMPLIANCE)

Document Control

• Effective Date: [Date]
• Version: 1.0 (Compliance Standard: Davis-Bacon Act / State Prevailing Wage)
• Jurisdiction: [State/Federal Jurisdiction]
• Project Name/Number: [Project Name/ID]

1. OFFICIAL NOTICE AND DISCLAIMER

This document constitutes a formal record of wages paid to laborers and mechanics employed on public works projects. Submission of this document is mandatory under [Applicable Statute, e.g., 40 U.S.C. § 3145]. NOTICE: The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal prosecution under Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code. Failure to comply with prevailing wage requirements may result in contract termination, debarment, and mandatory restitution.

2. IDENTIFICATION OF PARTIES

• Prime Contractor: [Full Legal Name of Prime Contractor]
• Subcontractor: [Full Legal Name of Subcontractor]
• Payroll Period Start: [Date] | Payroll Period End: [Date]

3. OPERATIVE CLAUSES

Clause 1: Compliance Certification. The undersigned representative affirms that during the period stated above, all persons employed on the project have been paid the full weekly wages earned, without rebate, either directly or indirectly, from the full weekly wages earned by any person, other than permissible deductions as defined in the regulations.

Clause 2: Wage and Benefit Verification. All payroll records, including fringe benefits, are in strict accordance with the Wage Determination (WD) issued for this contract. The undersigned confirms that no deductions have been made other than those expressly permitted by applicable law (e.g., taxes, authorized union dues, bona fide fringe benefit plans).

Clause 3: Accuracy of Labor Classifications. Each employee listed in the accompanying payroll attachment has been classified in accordance with the work performed. No laborer or mechanic has been paid at a rate less than the prevailing wage rate for the applicable craft/classification.

Clause 4: Record Retention. The contractor agrees to maintain these records and all supporting documentation (timecards, canceled checks, benefit plan documents) for a minimum of [3-5] years, subject to audit by the contracting agency or Department of Labor.

4. SIGNATURE AND ACKNOWLEDGMENT BLOCK

I, the undersigned, an authorized officer of the company, do hereby attest under penalty of perjury that the information contained herein is true, correct, and complete.

• Authorized Signature: ____________________________________
• Printed Name: [Name of Signatory]
• Title: [Title]
• Company Name: [Company Name]
• Date of Execution: [Date]

5. STEP-BY-STEP EXECUTION GUIDE

• Step 1: Classification Audit. Before filing, cross-reference every employee’s role against the project-specific "Wage Determination" provided by the contracting agency to ensure the hourly rate meets or exceeds the minimum.
• Step 2: Attachment Integration. Attach a detailed payroll ledger (spreadsheet) to this form. The ledger must include: Employee Name, Last 4 of SSN, Work Classification, Daily/Total Hours Worked, Hourly Rate of Pay, Gross Wages, Itemized Deductions, and Net Wages Paid.
• Step 3: Verification of Fringe Benefits. If fringe benefits are paid to third-party plans, attach the "Statement of Compliance" confirming the validity of these plans; if paid in cash, ensure the amount is clearly reflected in the "Gross Wages" column of the ledger.
• Step 4: Submission. Submit the signed original of this document along with the supporting ledger to the Contracting Officer or Agency Representative by the specified deadline (typically 7 days post-payroll period). Retain an electronic copy in a secure, encrypted document management system.