California Public Works Payroll Reporting FormCalifornia Public Works Payroll Reporting Form
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PUBLIC WORKS PAYROLL REPORTING FORM

California
Department of
Industrial Relations

Page ______ of ______
NAME OF CONTRACTOR:

CONTRACTOR'S LICENSE NO.:

OR SUBCONTRACTOR:
PAYROLL NO.:

FOR WEEK ENDING:
(4)

NAME, ADDRESS AND
SOCIAL SECURITY NUMBER
OF EMPLOYEE

(2)
NO. OF WITHHOLDING
EXEMPTIONS

(1)

DAY
M

(3)

ADDRESS:

SPECIALITY LICENSE NO.:

T

W

TH

F

S

DATE

WORK
CLASSIFICATION

(5)

(6)

TOTAL
HOURS

HOURLY
RATE
OF PAY

SELF-INSURED CERTIFICATE NO.:

PROJECT OR CONTRACT NO.:

WORKERS' COMPENSATION POLICY NO.:

PROJECT AND LOCATION:
(9)

(7)

(8)

GROSS AMOUNT
EARNED

DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS

S

NET WGS
PAID FOR
WEEK

CHECK
NO.

HOURS WORKED EACH DAY
THIS
PROJECT

ALL
PROJECTS

FED.
TAX

FICA
(SOC. SEC.)