Submitted Certified Payroll

Some prefilled data has been taken from the New Jersey Department of Labor & Workforce Development. If your Trade name, FEIN, Business Address or Certificate Registration Number are incorrect, please contact njwagehubinfo@dol.nj.gov.

For any other corrections, please update the details of this project or contact the contract owner.

Trade Name

Project Name

Contract ID / Project ID

Business Address

Contractor Registration Certificate Number

Project Location (Address City, County)

Payroll Number

Date Wages Due & Paid

Week Ending Date*

Final CertificationNo Work Week

(a) Fringe benefits are paid to approved plans, funds or programs

In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above-referenced payroll, payments of fringe benefits have been or will be made when due to appropriate programs for the benefit of such employees.

(b) Fringe benefits are paid in cash

Each laborer or mechanic listed in the above-referenced payroll has been paid as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract.

I, the undersigned, do hereby state and certify:

(1) That I pay or supervise the payment of the persons employed by

(Contractor or Subcontractor) on the

(Project Name & Location) that during the payroll period beginning on

and ending on

, all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of the aforenamed Contractor or Subcontractor from the full weekly wages earned by any person and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible dedutions as defined in the New Jersey Prevailing Wage Act, N.J.S.A.34:11-56.25 et seq, and Regulation N.J.A.C.21:60 at seq. and the Payment of Wages Law, N.J.S.A.34:11-4.1 et seq.

(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for laborers or mechanics contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each laborer or mechanic conform with the work he performed.

(3) That any apprentices employed in the above period are duly registered with the United States Department of Labor, Bureau of Apprenticeship and Training and enrolled in a certified apprenticeship program.

(4) (a) FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS OR PROGRAMS

In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above-referenced payroll, payments of fringe benefits have been or will be made when due to appropriate programs for the benefit of such employees.

(b) FRINGE BENEFITS ARE PAID IN CASH

Each laborer or mechanic listed in the above-referenced payroll has been paid as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract.

(5) N.J.S.A. 12:60-2.1 and 5.1 – The Public Works employers shall submit to the public body or lessor a certified payroll record each pay period within 10 days of the payment of wages.

By checking this box and typing my name below, I am electronically signing this application. I understand that an electronic signature has the same legal effect as a written signature. *

Name*

Title

Date*

THE FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL PROSECUTION. — N.J.S.A. 34:11- 56.25 ET SEQ. AND N.J.A.C. 12:60 ET SEQ. AND N.J.S.A. 34:11-4.1 ET SEQ.

New Jersey Wage Hub

Certified Payroll Submission

1. Company Details

2. Employee Hours Worked & Deductions

3. Fringe Benefits

(a) Fringe benefits are paid to approved plans, funds or programs

(b) Fringe benefits are paid in cash

4. Certification