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									Form DC-127 12/29/2011

                                                   NEW JERSEY DEPARTMENT OF TRNSPORTATION
                                                MONTHLY CERTIFICATION OF CONTRACTOR’S PAYROLLS
                                                                                            SEE REVERSE SIDE FOR INSTRUCTIONS



PROJECT                                                                                                       FEDERAL
                                                                                                                                                                 DP NO:
NAME:                                                                                                         PROJECT NO:




                                                                            SUBCONTRACTOR
                                                               CONTRACTOR
                                                                                                                                                                            NUMBER OF
                                                                                                DATE OF
                                                                                                                                                                            WAGE RATE
                                                                                                 LAST
                                                                                                                                                                            INSPECTION
                  NAME OF EMPLOYER                                                             PAYROLL               DATES OF PAYROLLS VERIFIED BY THIS REPORT
                                                                                                                                                                            SUBMITTED
                                                                                               PRIOR TO
                                                                                                                                                                              W/THIS
                                                                                              THIS REPORT
                                                                                                                                                                              REPORT




I certify that, to the best of my knowledge all employees working on this project during this period have been included on a payroll and all payrolls listed above, have been verified,
reviewed and accepted in accordance with contract requirements.

                           _______________________________________________________________                                      _____________________________
                                                 RE (Signature)                                                                 Date
                                        INSTRUCTIONS

List the names of each employer for which payrolls were received and reviewed.

Check whether the employer is the Contractor or a Subcontractor.

Show the week ending date of the payroll which was last verified, if any for each employer.

List the week ending dates of each payroll being verified as received and reviewed for the month.

Show the number of Wage Rate inspections which have been completed and are being submitted with this report.
Note: One Wage Rate Inspection is interpreted to mean the interviewing of one (1) employee.

								
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