Attachment - DOL Payroll Form

U.S. Department of Labor

PAYROLL

Wage and Hour Division

(For Contractor's Optional Use; See Instructions at www.dol.gov/whd/forms/wh347instr.htm) Rev. Dec. 2008

Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number.

NAME OF CONTRACTOR

ADDRESS

OR SUBCONTRACTOR

NAME AND INDIVIDUAL IDENTIFYING NUMBER

(e.g., LAST FOUR DIGITS OF SOCIAL SECURITY

NUMBER) OF WORKER

(2)

(3)

WORK

CLASSIFICATION

(4) DAY AND DATE

(5)

(6)

(7)

HOURS WORKED EACH DAY

TOTAL

HOURS

RATE

OF PAY

GROSS

AMOUNT

EARNED

OT. OR ST.

(1)

PROJECT OR CONTRACT NO.

PROJECT AND LOCATION

FOR WEEK ENDING

NO. OF

WITHHOLDiNG

EXEMPTIONS

PAYROLL NO.

OMB No.:1235-0008

Expires: 04/30/2021

(9)

(8)

DEDUCTIONS

FICA

WITHHOLDING

TAX

OTHER

NET

WAGES

TOTAL

PAID

DEDUCTIONS FOR WEEK

O

S

O

S

O

S

O

S

O

S

O

S

O

S

O

S

While completion of Form WH-347 is optional, it is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the information collection contained in 29 C.F.R. §§ 3.3, 5.5(a). The Copeland Act (40 U.S.C. § 3145) contractors and subcontractors performing work on Federally 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 at 29 C.F.R. § 5.5(a)(3)(ii) require contractors to submit weekly a copy of all payrolls to the Federal agency 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. Public Burden Statement
We estimate that is will take an average of 55 minutes to complete this collection, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding these estimates or any other aspect of this collection, including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S3502, 200 Constitution Avenue, N.W. Washington, D.C. 20210
(over)

Date
I,