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Get CA A-1-131 1980

HOURS WORKED EACH DAY THIS PROJECT ALL FED. TAX FICA SOC. SEC. TRAING. FUND ADMIN STATE SDI VAC/ HOLIDAY HEALTH WELF. PENSION SAVINGS OTHER DEDUCTIONS DUES TRAV/ SUBS. O S STRAIGHT TIME Form A-1-131 New 2-80 O OVERTIME SDI STATE DISABILITY INSURANCE OTHER Any other deductions contributions and/or payments whether or not included or required by prevailing wage determinations must be separately listed. Use extra sheet s if necessary CERTIFICATION MUST be completed See reverse side NOTICE TO PUBLIC ENTITY For Privacy Considerations Fold back along dotted line prior to copying for release to general public private persons. PUBLIC WORKS PAYROLL REPORTING FORM California Department of Industrial Relations Page of NAME OF CONTRACTOR CONTRACTOR S LICENSE NO. OR SUBCONTRACTOR PAYROLL NO. FOR WEEK ENDING NAME ADDRESS AND SOCIAL SECURITY NUMBER OF EMPLOYEE NO. OF WITHHOLDING EXEMPTIONS DAY M ADDRESS SPECIALITY LICENSE NO. T W TH F S DATE WORK CLASSIFICATION SELF-INSURED CERTIFICATE NO. TOTAL HOURS HOURLY RATE OF PAY PROJECT OR CONTRACT NO. WORKERS COMPENSATION POLICY NO. PROJECT AND LOCATION GROSS AMOUNT EARNED DEDUCTIONS CONTRIBUTIONS AND PAYMENTS NET WGS PAID FOR WEEK CHECK NO. Paper Size then 8-1/2 x 11 inches the undersigned am the I Name print with the authority to act for and on behalf of Position in business certify under penalty of perjury Name of business and/or contractor that the records or copies thereof submitted and consisting of Description number of pages are the originals or true full and correct copies of the originals which depict the payroll record s of the actual disbursements by way of cash check or whatever form to the individual or individuals named* Date Signature A public entity may require a stricter and/or more extensive form of certification*. OR SUBCONTRACTOR PAYROLL NO. FOR WEEK ENDING NAME ADDRESS AND SOCIAL SECURITY NUMBER OF EMPLOYEE NO. OF WITHHOLDING EXEMPTIONS DAY M ADDRESS SPECIALITY LICENSE NO. T W TH F S DATE WORK CLASSIFICATION SELF-INSURED CERTIFICATE NO. OF WITHHOLDING EXEMPTIONS DAY M ADDRESS SPECIALITY LICENSE NO. T W TH F S DATE WORK CLASSIFICATION SELF-INSURED CERTIFICATE NO. TOTAL HOURS HOURLY RATE OF PAY PROJECT OR CONTRACT NO. WORKERS COMPENSATION POLICY NO. PROJECT AND LOCATION GROSS AMOUNT EARNED DEDUCTIONS CONTRIBUTIONS AND PAYMENTS NET WGS PAID FOR WEEK CHECK NO. OR SUBCONTRACTOR PAYROLL NO. FOR WEEK ENDING NAME ADDRESS AND SOCIAL SECURITY NUMBER OF EMPLOYEE NO. OF WITHHOLDING EXEMPTIONS DAY M ADDRESS SPECIALITY LICENSE NO. T W TH F S DATE WORK CLASSIFICATION SELF-INSURED CERTIFICATE NO. TOTAL HOURS HOURLY RATE OF PAY PROJECT OR CONTRACT NO. WORKERS COMPENSATION POLICY NO. PROJECT AND LOCATION GROSS AMOUNT EARNED DEDUCTIONS CONTRIBUTIONS AND PAYMENTS NET WGS PAID FOR WEEK CHECK NO. .

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