Certified Payroll Form

Certified payroll form is mainly used by contractors who pay a certain specified wage rate for workers on the job. For each payroll period, the contractor must create a certified payroll form that shows the wages paid to each worker. The form contains information about who worked on the job and how much they were paid. Below is a sample certified payroll form.

Sample Certified Payroll Form

Please fill in the details below:

Employer Name: _________________ Address: _______________________

Project Number: __________________________________________________

Employee Name: ______________________ Address: _______________________

Employee Number: ___________________________________________________

Employee grade: ___________________________________________________

Hours Worked: ____________________________________________________

Project total hours: _________________________________________________

Base rate: _________________________________________________________

Total tax deductions: ________________________________________________

Statutory deductions: _______________________________________________

Other deductions: _________________________________________________

Net paid: ________________________________________________________

This is to certify that I supervise and pay the employee shown above. During the pay period reported, all hours worked on this project have been paid at the appropriate prevailing wage rate. All benefits have been paid and the necessary deductions from the total wages also made.

Name: ___________________________________________________

Title: ____________________________________________________

Signature: ________________________ Date: __________________________

Category: Payroll Forms