Spreadsheet: 0533958e-1ed1-4f3c-bdfe-fd9fe7e9d53a
Sheet: Sheet1

BEST Division | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12 | Unnamed: 13 | Unnamed: 14 | Unnamed: 15 | Unnamed: 16 | Unnamed: 17 | Unnamed: 18 | Unnamed: 19 | Unnamed: 20 | Unnamed: 21 | Unnamed: 22 | Unnamed: 23 | Unnamed: 24 | Unnamed: 25 | Unnamed: 26 | Unnamed: 27 | PAYROLL | Unnamed: 29 | Unnamed: 30 | Unnamed: 31 | Unnamed: 32 | Unnamed: 33 | Unnamed: 34 | Unnamed: 35 | Unnamed: 36 | Unnamed: 37 | CC-13 Weekly Certified Payroll Form | Unnamed: 39 | Unnamed: 40 | Unnamed: 41 | Unnamed: 42 | Unnamed: 43 | Unnamed: 44 | Unnamed: 45 | Unnamed: 46 | Unnamed: 47 | Unnamed: 48 | Unnamed: 49 | Unnamed: 50 | Unnamed: 51 | Unnamed: 52 | Unnamed: 53 | Unnamed: 54 | Unnamed: 55 | Unnamed: 56 | Unnamed: 57
(For Contractor's Optional Use) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Rev. Dec. 2010
NAME OF CONTRACTOR OR SUBCONTRACTOR |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | ADDRESS
PAYROLL NO. |  |  |  |  |  |  |  |  |  |  | FOR WEEK ENDING |  |  |  |  |  |  |  |  |  | PROJECT AND LOCATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | PROJECT OR CONTRACT NO.
(1) |  |  |  |  |  |  |  |  |  | (2) |  |  | (3) |  |  |  |  |  |  |  | OT . OR  ST. | (4) DAY AND DATE |  |  |  |  |  |  | (5) |  | (6) |  |  | (7) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | (9)
NAME AND INDIVIDUAL IDENTIFYING NUMBER (e.g. LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER) OF WORKER |  |  |  |  |  |  |  |  |  | NO. OF | WITHHOLDING | EXEMPTIONS | WORK CLASSIFICATION (please provide wage determination code) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | TOTAL  HOURS |  | DB RATE OF  PAY (hourly rate) |  | STANDARD RATE OF PAY (hourly rate) | DB  GROSS  AMOUNT  EARNED |  |  | STANDARD GROSS AMOUNT EARNED | Difference between DB & Standard | (8) DEDUCTIONS |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | NET WAGES PAID FOR WEEK
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | FICA |  |  | WITH- HOLDING TAX |  |  | MEDICARE |  |  | STATE |  |  | OTHER |  |  | TOTAL DEDUCTIONS
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | HOURS WORKED EACH DAY
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | O |  |  |  |  |  |  |  | 0 |  |  |  |  | 0 |  |  | 0 | 0 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | S |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | O |  |  |  |  |  |  |  | 0 |  |  |  |  | 0 |  |  | 0 | 0 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | S |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | O |  |  |  |  |  |  |  | 0 |  |  |  |  | 0 |  |  | 0 | 0 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | S |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | O |  |  |  |  |  |  |  | 0 |  |  |  |  | 0 |  |  | 0 | 0 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | S |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | O |  |  |  |  |  |  |  | 0 |  |  |  |  | 0 |  |  | 0 | 0 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | S |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | O |  |  |  |  |  |  |  | 0 |  |  |  |  | 0 |  |  | 0 | 0 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | S |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | O |  |  |  |  |  |  |  | 0 |  |  |  |  | 0 |  |  | 0 | 0 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | S |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | O |  |  |  |  |  |  |  | 0 |  |  |  |  | 0 |  |  | 0 | 0 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | S |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | O |  |  |  |  |  |  |  | 0 |  |  |  |  | 0 |  |  | 0 | 0 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | S |  |  |  |  |  |  |  | 0
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 |  |  | 0 | 0
While completion of this form is optional, it is mandatory for covered contractors and subcontractors performing work on some BEST financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. Parts 3.3, 5.5(a). The Copeland Act (40 U.S.C. 3145) requires contractors and subcontractors performing work on some BEST financed or assisted construction contracts to "furnish weekly a statement with respect to the wages paid each employee during the  preceding week."  U.S. Department of Labor (DOL) Regulations 29 CFR Part 5.5(a)(3)(ii) require contractors to submit weekly a copy of all payrolls to the BEST grantee contracting for or  financing the construction project, accompanied by a signed "Statement of Compliance" indicating that the payrolls are correct and complete and that each laborer or mechanic has been paid not less than the proper  Davis-Bacon prevailing wage rate for the work performed. DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits.
Date
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | ( b )  WHERE FRINGE BENEFITS ARE PAID IN CASH
I, |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | ,
 |  |  | (Name of Signatory Party) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | (Title) |  |  |  |  |  |  |  |  |  |  | * 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 )  below,
do hearby state:
 | (1) That I pay or supervise the payment of the persons employed by
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | ( c ) EXCEPTIONS
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | on the
 |  |  |  |  |  |  |  |  |  |  | (Contractor or Subcontractor)
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | * Exception (Craft) Please provide an explanation:
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | ; that during the payroll period commencing on the
 |  |  | (Building or Work)
 |  |  | day of |  |  |  |  |  |  |  | , |  |  |  |  | and ending the |  |  |  |  |  |  | day of |  |  | , |  | ,
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 the behalf of said
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | from the full
 |  |  |  |  |  |  |  |  |  |  | (Contractor or Subcontractor)
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 Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Start. 108, 72 Stat. 967; 76 Stat, 357; 40 U.S.C. 276c), and described below:
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Remarks:
 | (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 they performed.
 | (3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, of if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.
 | (4) That:
 |  | ( a ) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS OR PROGRAMS |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Name and Title |  |  |  |  |  |  |  |  |  |  | Signature
 |  |  |  | * 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 Section 4(c) below. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal prosecution. See section 1001 of title 18 and section 231 of title 31 of the United States Code.