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U Local# _____ E _________ O_________ OT INSTRUCTIONS ON REVERSE SIDE FALSIFICATION OF THIS STATEMENT IS A PUNISHABLE OFFENSE This certified payroll has been prepared in accordance with the instructions contained on the reverse side of this form. I certify that the above information represents wages and supplemental benefits paid to all persons employed by my firm for construction work on the above project during the period shown. I understand that falsification of this statement is a punisha.

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