PUBLIC WORKS PAYROLL REPORTING FORM

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1 California Department of Industrial Relations PUBLIC WORK PAYROLL REPORTING FORM Page of NAME OF CONTRACTOR: CONTRACTOR' LICENE NO.: ADDRE: OR UBCONTRACTOR: PECIALITY LICENE NO.: PAYROLL NO.: FOR WEEK ENDING: ELF-INURED CERTIFICATE NO.: PROJECT OR CONTRACT NO.: (4) DAY (5) (6) WORKER' COMPENATION POLICY NO.: PROJECT AND LOCATION: (1) NAME, ADDRE AND OCIAL ECURITY NUMBER OF EMPLOYEE (2) (3) M T W TH F DATE WORK CLAIFICATION HOUR WORKED EACH DAY HOUR HOURLY RATE OF PAY (7) GRO AMOUNT EARNED (8) DEDUCTION, CONTRIBUTION AND PAYMENT NET WG PAID FOR WEEK (9) CHECK NO. NO. OF WITH- HOLDING EXEMPTION THI PROJECT ALL PROJECT FED. TAX FICA (OC. EC.) TATE TAX DI VAC/ HOLIDAY HEALTH & WELF. PENION O TRAING. FUND ADMIN DUE TRAV/ UB. AVING OTHER* DEDUC- TION THI PROJECT ALL PROJECT FED. TAX FICA (OC. EC.) TATE TAX DI VAC/ HOLIDAY HEALTH & WELF. PENION O TRAING. FUND ADMIN DUE TRAV/ UB. AVING OTHER* DEDUC- TION THI PROJECT ALL PROJECT FED. TAX FICA (OC. EC.) TATE TAX DI VAC/ HOLIDAY HEALTH & WELF. PENION O TRAING. FUND ADMIN DUE TRAV/ UB. AVING OTHER* DEDUC- TION THI PROJECT ALL PROJECT FED. TAX FICA (OC. EC.) TATE TAX DI VAC/ HOLIDAY HEALTH & WELF. PENION O TRAING. FUND ADMIN DUE TRAV/ UB. AVING OTHER* DEDUC- TION MUT = TRAIGHT TIME *OTHER Any other deductions, contributions and/or payments whether or not included or required by prevailing CERTIFICATION be completed Form A (New 2-80) O = OVERTIME wage determinations must be separately listed. Use extra sheet(s) if necessary (ee reverse side) DI = TATE DIABILITY INURANCE

2 PAYROLL REPORT DATA: DLE (Form A-I-l3I) or GLC (Form #36) CERTIFIED PAYROLL RECORD: All payrolls are to be submitted to GOLDEN TATE LABOR COMPLIANCE LLC for review during the course of the contract in conformance with the schedule for submitting payroll as stated within the General Requirements of the contract documents. 1. All payroll reports must be on forms provided by the DLE (Form A-I-l3I) or GLC s payroll report or in another format which shall contain the following information: The name, address, and social security number of each worker, are legible and not blacked out. His or her full work classification with description, if necessary, including group # s and steps/levels of apprentices. The rate of pay per hour, including rates of contributions for/or costs assumed to provide fringe benefits. If the basic hourly rate is indicated, then the fringes on the fringe benefit statement need to add up with the total prevailing rate for that classification, Regular, overtime and holiday hours indicated daily and the total weekly number of hours worked, Deductions made, and actual wages paid, Net Wages and Check # The contractors full name and address, The project name and location, The dates the payroll covers. All days for a project MUT be accounted for, including aturdays, undays, & Holidays. 2. Each individual, laborer, or craftsperson working on the Project must appear on the CPRs. Each Contractor who pays a worker must report that individual on its CPRs, including each individual working as an apprentice in an apprenticeable trade. This applies as well to Contractors employing owner-operators, sole proprietors, and partners. Owner-operators, sole proprietors, and partners performing labor also must report their wages. imilarly, rental companies paying rental equipment operator's wages must report those wages. 3. The contractor must complete a Non-Performance Report Form for all periods of inactivity. This form is filled out when no work is performed on the project for a period of time. On the form the contractor will state that there was no payroll for that period. It does not matter what day the weekly payroll period begins and ends. 4. The final payroll form must be marked final by the contractor. When the final payroll is received from each contractor; the log will then be closed out and marked complete.

3 CHANGE TO PREVAILING RATE AFTER AWARD: (California Labor Code ) No effect once the contract notice to bidders is published. If during any quarterly period the Director of Industrial Relations shall determine that there has been a change in any prevailing rate of per diem wages in any locality he shall make such change available to the awarding body and his determination shall be final. uch determination by the Director of Industrial Relations shall not be effective as to any contract for which the notice to bidders has been published. PERON REQUIRED TO RECEIVE PREVAILING WAGE: (California Labor Code 1771 and 1774) The contractor to whom the contract is awarded, and any subcontractor under him, shall pay not less than the specified prevailing rates of wages to all workmen employed in the execution of the contract. The Awarding Body s General Conditions require all workers not in a prevailing wage classification to be paid the wage most closely related to the craft or trade they are involved with. GENERAL PREVAILING RATE OF PER DIEM WAGE INCLUDE: (1) The prevailing basic straight-time hourly rate of pay; and (2) The prevailing rate for holiday and overtime work; and (3) The prevailing rate of employer payments for any or all programs or benefits. GENERAL CONTRACTOR REPONIBILITIE FOR UBCONTRACTOR: (California Labor Code 1775.) Each prime contractor(s) is responsible for ensuring that all its subcontractors of any tier comply with the prevailing wage requirements. The prime contractor must monitor the subcontractors' payment of the specified general prevailing wages to their employees by periodically reviewing the subcontractors' CPRs. Upon becoming aware that a subcontractor has failed to apply the specified prevailing rate of wages, the prime contractor must take corrective action to halt or rectify the failure, including, but not limited to, retaining sufficient funds due the subcontractor for work performed on the public works project. Prior to making a final payment to the subcontractor for work performed on the public works project, the prime contractor should obtain an affidavit signed under penalty of perjury from the subcontractor that the subcontractor has paid the general prevailing rate of per diem wages to its employees on the public works project, as well as any penalties which may have been imposed for working hour s violations.

4 Name of Contractor: ATLA C ONTRUCTION Co ntractorts License No.: Class : Or ub Contractor: peci alty License No.: Address of Contractor: MAIN TREET Workman s Compensation Policy No.: C54321 Reporting Fo rm Cit y, tate, Zip: ANYWHWERE, CA Project and Location: HAPPY DAZE E WIDE TREET, ANYWHERE, CA Name, Address and Payroll Number: 1 Week Ending: 00/06/0000 PayDate: 00/04/0000 ocial ecurity Number Work DAY / DATE Hourly Gross Amount Net, of Employee Classification M T W T F Total Pay Earned Deductions, Contributions Wages Check Hours Rate and Payments for No. HOUR WORKED EACH DAY Week This All Fed.Tx. FICA tate Tax JOHN E. WORKER /T MAIN TREET ELECTRICIAN Project Projects ANAHEIM, CA INIDE DI VAC H&W WIREMAN O/T Pension Training Admin. # Trv./ubs. *Other Total Ded. D/T IAM WORKER LABORER /T This All Fed.Tx FICA tate Tax Project Projects DI VAC H&W 567 LABOR RD GROUP # 2 O/T VENTURA, CA Pensi on Trainin g Admin. # D/T Trv./ubs. *Other Total Ded This All Fed.Tx. FICA tate Tax GOT A, JOB PLUMBER /T HOME PIPEFITTER Project Projects VIALIA,CA DI VAC H&W # O/T Pension Training Admin. D/T 7.52 Trv./ubs. *Other Total Ded GLC #36AMP. (1/09) /T=traight Time- O/T=Overtime- D/T=Double Time *Other- Include explanation of Other deductions

5 TATEMENT OF COMPLIANCE Date I, do hereby certify under penalty of perjury: (Name of signatory party) / (Title) (1) That I pay or supervise the payment of the persons employed by (Contractor or subcontractor) on the, that during the payroll period commencing on the (Building or work) day of, 20 and ending the day of, 20, all persons employed on said project have been paid their full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said from (Contractor or subcontractor) 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 deductions, as described below: (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 or she performed. (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a tate apprenticeship agency. (4) That: (a) WHERE FRINGE BENEFIT ARE PAID TO APPROVED PLAN, FUND OR PROGRAM In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in ection 4(c) below. (b) WHERE FRINGE BENEFIT ARE PAID IN CAH 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, except as noted in ection 4(c) below: (c) EXCEPTION EXCEPTION(CRAFT) EXPLANATION Remarks: Name and Title: ignature: The willful falsification on any of the above statements may subject the contractor or subcontractor to civil or criminal prosecution. ee ection 1001 of Title 16 and ection 231 or Title 31 of the United tates Code.

6 PAYROLL CERTIFICATION (TATEMENT OF COMPLIANCE) Form (GLC #61) (CLC 1776.(a) (1) & (2) or CCR 16401) Each payroll shall have an attached certification. The certification must contain specific language as established by the Director of Industrial Relations, The certification shall have an affirmation of a person with the authority to affirm the certification, under the penalty of perjury that the records are originals or are full, true and correct copies of the original. GLC form #61 is the only payroll certification that will be accepted under the Golden tate Labor Compliance program, as adopted by the Awarding Body. CERTIFYING PERON: A person with the authority to affirm under penalty of perjury that the records provided, depict truly, fully and correctly the type of work performed, the hours worked, days worked and amounts paid. CALIFORNIA CODE OF REGULATION, TITLE 8, GROUP 3, ARTICLE 1, DEFINITION. PAYROLL PERIOD: The Payroll period may start and end on any day of the week. Insert the beginning and ending dates of the payroll period. Each payroll report shall not include more that seven consecutive days. NUMBER OF PAGE: Insert the number of pages submitted. OTHER DEDUCTION: These may include, but are not limited to, court ordered payment and wage garnishments OPTIONAL BENEFIT PLAN: Deductions for company sponsored programs such as 401k, medical or any other qualifying program which has been acknowledged, in writing, by the employee shall be listed and fully described on the Payroll Certification or an attachment sheet. Provide documentation of the employees authorization for deductions and/or any court ordered payments or wage garnishments. METHOD OF DITRIBUTING FRINGE BENEFIT: Check the appropriate box which indicates how the fringe benefits have been disbursed, to Plans or in Cash to the employee and list below any exceptions that are applicable. NOTE: Training Fund Contributions must be paid to an approved Joint Apprenticeship Training Committee or the California Apprenticeship Committee. The only instance where the employee may receive the money as a direct payment is if the Trade or Craft has been determined to be a non-apprenticable trade. ign and Date the certification include the Project name and your payroll #. This certification must be received by Golden tate LC as a wet signature, original document.

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