251-26 - Cert Payroll 1 - 6.12.26_Redacted.pdf

SUBMIT form by email: equalpayact@dol.nj.gov IMPORTANT: For purposes of law, you must also submit this form to the appropriate public body or lessor. Payroll Certification for Public Works Projects for Contractor and Subcontractor’s Weekly and Final Certification Name of  Contractor or  Subcontractor F.E.I.N. Business Address Project Location Payroll No. Week Ending Date or  Final Certification NJ Department of Labor & Workforce Development Project Name Contract I.D. or Project I.D. Contractor Registration #Date Wages Due & Paid (mm/dd/yyyy) W= White; B= Black or African American; A= Asian; N= American Indian or Native Alaskan; I = Native Hawaiian or Pacific Islander; M= 2 or More MW-562 (9/19)  Check if additional sheets used 1. 5. 6. 9. 10. Job Title Sex Race SU MO TU WE TH FR SA Hourly M=Male F=Female and Address journeyman, foreman e.g., carpenter, mason, plumber X=Non-Binary Hours of Pay Project Week FICA O O S S O O S S O O S S O O S S S O 2. Work Hours worked each day DeductionsGross Amt. Earned Straight Time or Overtime 3. Demographics 7. 8.4. Day and Date mm/dd mm/dd mm/dd mm/dd mm/dd mm/ddEmployee Name mm/dd Total Deductions Net Wages Paid for Week Total Fringe Benefit Cost/Hour e.g., apprentice, Work Classification/ Occupational Category See Key Federal Tax Total Rate This This State Tax Other (specify) Other (specify)

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 (date) _____________, and ending on (date) _____________, 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 deductions 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. 12:60 et 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 sub- mitted 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 in- corporated 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) That: (a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS OR PROGRAMS q 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 employ-ees, as noted in Section 4(c) at right. (b) WHERE FRINGE BENEFITS ARE PAID IN CASH q 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 Section 4(c) at right. (5) N.J.S.A. 12:60-2.1 and 5.1 – The Public Works employers shall sub- mit to the public body or lessor a

required fringe benefits as listed in the contract, except as noted in Section 4(c) at right. (5) N.J.S.A. 12:60-2.1 and 5.1 – The Public Works employers shall sub- mit to the public body or lessor a certified payroll record each pay period within 10 days of the payment of wages. (6) 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 (mm/dd/yy) ______________ 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. Program Title, Classification Title, or Individual Workers Health/ Welfare Vacation/Holiday Apprenticeship/ Training Pension Other Benefit Type and Amount (e.g., training, long-term disability or life ins.) Name & Address of Fringe Benefit Fund, Plan, or Program Administrator USDOL Benefit Plan Filing Number/EIN Third-Party Trustee &/or Contract Person 4(c) Benefit Program Information in AMOUNT CONTRIBUTED PER HOUR (Must be completed if 4(a) is checked) To calculate the cost per hour, divide 2,000 hours into the benefit cost per year per employee.