Sample Certified Payroll - EERE

(1,P'AYROILL(For COllitractor's OIIJ~ional Use· See Ins'IJ1I1c,ti,ons atwwW'.dal.gov!October 17, 20096;1, of'E1 Easy Sbeet. New Y(II(, NY1st at AAvenueage 1 012hdlform, 3471 , UJh1m)fy ,O.l.f8«IR ' ~,6 - story OfficeAnderson, Joseph'Ca~r 0 1 1 1 1 1 5 35.96 +.~L 67A3 ~'79.80 179811"""'''''' II 8 8 8 8 8 40 17.98 I~I [I ' ., "OcHERETi'E":JTOTlo\L P ;)!;;1DIJCli.c",J ' ro." ~'oI'EEK2651 63379Bedwel ;ThomasCarpenter II: 1 1 1 11 '1 5 2Q.031 ~'%: 61 45l~63.87 16 39 1g 88 181 8 8 40 17.98 r7~~ . I' .341.71 71..64Larson t Toddcarpenter' 111 1 1,11 5 20,.O,3~~~'47 561126.8~ 1269, Ie 8 8 818 8 40 13.351/~ .. 'I J1J .,11!08, 447.07OIBrian. Tom~15 356.46Roberts. Gordon18 8 818 8 40 12.641~~ 37.92 1101.12 0.11149.15, 356.45,Snyder, Hammon1~15 356.45Cremen~ Pau E.0'c'unn·,n-_n1'III_-a. am,O'hristopher' BricldawMr j 1M"~~ - -~-' Hef-----b116..---~'::-:-~--:"-=-7+'7'-+---"-6+--+32 y; 17.44: ~~ .- 'I .W .' - II ..~~ 2 160 1 1'1'3' aIlo 1136 1~.Loon to 25914 .2&.29Bank$100XliiYlblfc-?,..aiC!d C~OCt7;KXClI id s.LbcooIi.olic..~, . ¥.ak on ".:!.: .«:1 OiiiilCli :5,'X!d c -.co CJX'I.'hIiC..~ i:O p:aj ~ I b:. c.ollc!::-.co a:o~ I ~ "'--5. -ro iii'" ~ ~........ ,II.. ill c.opoJ. . 'NOOkon I '/" C!dOii~~C_OCISt.fD: .coca::r.~s.r.o. :SO! as.." - ~'M ~~r.o ~Cd, d~ afOtO pro: 'N!C!dC:.1io.... ':~!..ata'~M¥.cQ ~~,l:bopayrol!5, C_omD:~.,;:Ic~aoodo!'.

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Date october 17. 2009t. _-----'-';HE~N"+,H;:;"ardee~=__ --,--P,-",residen"",' "",---I_----="..,-----__(N13m.? of Signafory Pari:.') (Ti e)do hereby s,a:e:(1 ) That I payor '!iupelVise the pa)'ment of :.:he persons emplo)'erl byHale N. Hardee ConstruclIon Co" Inc.on ,he6_ 0IIice Bu (Confrac!or or 9.lbconttactor)Story Idirig ;fhat during the pa)'rcll period commencing on the(Buildi"" or Wort:.)11 d3.yof October 2009 anoden g~he __fl_daYOf October ~pe~ons employed on said project ha..,e been paid the full weekly wage; earned. iha.: no .-.:bates ha'iE'be-E11 or w. be made eitf1.e.r dIeetly or indirectily to or on behalf oi said___H'-'.a1'-...:...e'-'.N-'-.,H'-'.ard",-,,-ee,,:::-Col-'-'-'.~7-lStn,,-uction:;";::'-·7-"-Co-'-"-"7-'I,:-nc.,-,-(Contractor or Subcontracfor)from 'he lullweek!: wages earned by any pel'5On and tha~ .no deducuDns haVE! been made either dire~ or indirectlyfrom lhe full wages eame-d by any person, e-:her than pe.Im2Ssible dE