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Delaware ofLabor Delaware Department Department of PAYROLL REPORT NAME OF CONTRACTOR OR SUBCONTRACTOR State Division of of Industrial Affairs 225 Corporate of Boulevard 4425 N. Market Suite 104 Street Wilmington 19802 Newark DEDE 19702 302-761-8200 302-451-3423 PROJECT AND LOCATION ADDRESS WEEK ENDING DATE PHONE CONTRACT NUMBER DATE OF PREVAILING WAGE DETERMINATION USED ON THIS PROJECT DAY DATE HOURS WORKED EACH DAY NAME ADDRESS AND SOCIAL SECURITY NUMBER OF EMPLOYEE WORK CLASSIFICATION RATE OF PAY M S O DEDUCTIONS TOTAL HOURS T W F HOURS RATE GROSS NET AMOUNT WAGES EARNED FICA FWT SWT PAID HOURLY VALUE OF FRINGES DATE List only those fringe benefits I Name of signatory party For which the employer has paid and Which have been used to offset the full prevailing wage rate. Title do hereby state See Delaware Prevailing Wage Regulations for explanation of how hourly value of benefits is the be computed* That I pay or supervise the payment of persons employed by on the HOURLY COST OF BENEFITS List in same order shown on front of record Contractor or Subcontractor Employee public project that during the payroll period commencing on the and ending on 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 behalf of the 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 prevailing wage regulations of the State of Delaware. 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 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 performed* 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 and that the worksite ratio of apprentices to mechanics does not exceed the ratio permitted by the prevailing wage regulations of the State of Delaware. I hereby certify that the foregoing information is true and correct to the best of m knowledge and belief* I realize that making a false statement under oath is a crime in State of Delaware Signature STATE OF COUNTY OF SWORN TO AND SUBSCRIBED BEFORE ME A NOTARY PUBLIC THIS DAY OF A*D* 20 Notary Public An employer who fails to submit sworn payroll information to the Department of Labor weekly shall be subject to fines of 1 000. Title do hereby state See Delaware Prevailing Wage Regulations for explanation of how hourly value of benefits is the be computed* That I pay or supervise the payment of persons employed by on the HOURLY COST OF BENEFITS List in same order shown on front of record Contractor or Subcontractor Employee public project that during the payroll period commencing on the and ending on 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 behalf of the 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 prevailing wage regulations of the State of Delaware. 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 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 performed* 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 and that the worksite ratio of apprentices to mechanics does not exceed the ratio permitted by the prevailing wage regulations of the State of Delaware. .