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O. OF WITHHOLDiNG EXEMPTIONS NAME, ADDRESS, AND SOCIAL SECURITY NUMBER OF EMPLOYEE (2) (3) WORK CLASSIFICATION OMB No.: 1215-0149 Expires: 04/30/2009 PROJECT OR CONTRACT NO. PROJECT AND LOCATION FOR WEEK ENDING (4) DAY AND DATE (5) (6) (7) (9) (8) DEDUCTIONS OT. OR ST. PAYROLL NO. (1) Rev. April 2006 Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. OR SUBCONTRACTOR HOURS WORKED EACH DAY TOTAL HOURS.

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