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Address 1234 Main Street Contractor Name Payroll No. Project #1234 Project Name & Location City, State, Zip Any City, Any State, 12345 Phone No. Contract No. Public Authority (Owner) (123) 456-7890 Work Race/ Social Security Number3 Class3 Sex3 Hours Worked - Day & Date S John Doe, 1234 Smith Rd., Parma OH 44130, 123-456789 Iron Worker n.a. M T W Th F OT 2.00 ST 8.00 8.00 8.00 8.00 8.00 12/31/2005 Parking Lot Renovation Cuyahoga Community College Employee Name, Addres.

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