The Racial Contract by rmg15963

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									                                RACIAL CODES


RACIAL CODES:

            1 = WHITE AMERICAN

            2 = BLACK AMERICAN

            3 = NATIVE AMERICAN

            4 = HISPANIC AMERICAN

            5 = ASIAN PACIFIC

            6 = HASIDIC JEWS




                                   Page 1
                                                                                                                                 PAYROLL REPORTING FORM
                                                                                                                                                                                                                                                                                                                 PAGE 2 OF 6




NAME OF CONTRACTOR OR SUBCONTRACTOR                                                                              ADDRESS                                                                                                                                                              CONTRACTOR'S LICENSE NO:

COMPANY NAME                                                                                                                                          1540 S. LEWIS STREET, ANAHEIM, CA 92805                                                                                                            12345080
PAYROLL NO.                                          FOR WEEK ENDING                                             PROJECT NAME AND LOCATION                                                                                                                                            PROJECT/CONTRACT NO.

                                   1                                       01-Jan-08                                                                   LOS ANGELES BUILDING - SEISMIC STRUCTURE                                                                                                             C-00-000
                                                                                                                                                        12345 MAIN STREET, LOS ANGELES CA 90000
                             (1)          (2)                                 (3)                                                (4)                              (5)            (6)                    (7)                                                         (8)                                               (9)       (10)
                                                     (a)   (b)                                                              DAY AND DATE




                                                                                              O.T. OR S.T.
                                       WITHHOLDING
                                       EXEMPTIONS



                                                           RACIAL CODE
                NAME, ADDRESS, AND                                                                           M     T       W     T     F       S      S         TOTAL           RATE        GROSS              GROSS                                                                                               NET WAGE
                                          NO. OF

              SOCIAL SECURITY NUMBER                                         WORK                                                                              HOURS           OF PAY      AMOUNT             AMOUNT                        DEDUCTION, CONTRIBUTIONS AND PAYMENTS                                    PAID      CHECK
                     OF EMPLOYEE                     M/F                 CLASSIFICATION                                                                       (This Job)                   EARNED              EARNED                                                                                              FOR WEEK     NO.
                                                                                                                       HOURS WORKED EACH DAY
                                                                                                                                                                                           (This Job)         (ALL JOBS)

John Doe                                                                                                                                                                                                                   FED TAX:     FICA:     STATE TAX:      SDI:      VAC/HOL      H/W       PENSION

123 Main Street                                                           Electrical          S              8     8       8     8     6                         38             52.00                                        1.00       1.00         1.00         1.00       1.00        1.00          1.00
                                           7         M 1                                                                                                                                  2,171.00            2,500.00                                                                                             2,487.00    123456
Los Angeles CA 90000                                                      Foreman                                                                                                                                          TRAING.:   FUND AMD:     DUES:      TRAV/SUBS.   SAVING:    OTHER*    TOTAL DEDUC:

555-55-5555                                                                                  O               1     1       0.5                                   2.5            78.00                                        1.00       1.00         1.00         1.00       1.00        1.00        13.00
John W Smith                                                                                                                                                                                                               FED TAX:     FICA:     STATE TAX:      SDI:      VAC/HOL      H/W       PENSION

125 Main Street                                                           Carpenter           S              8     8       8     8     8                         40             38.00                                        1.00       1.00         1.00         1.00       1.00        1.00          1.00
                                           1         M 1                                                                                                                                  1,691.00            1,850.25                                                                                             1,837.25    123457
Los Angeles CA 90000                                                     Journeman                                                                                                                                         TRAING.:   FUND AMD:     DUES:      TRAV/SUBS.   SAVING:    OTHER*    TOTAL DEDUC:

555-55-5555                                                                                  O                                                 3                  3             57.00                                        1.00       1.00         1.00         1.00       1.00        1.00        13.00
                                                                                                                                                                                                                           FED TAX:     FICA:     STATE TAX:      SDI:      VAC/HOL      H/W       PENSION

                                                                                              S                                                                   0
                                                                                                                                                                                                  -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:     DUES:      TRAV/SUBS.   SAVING:    OTHER*    TOTAL DEDUC:

                                                                                             O                                                                    0                                                                                                                                     -
                                                                                                                                                                                                                           FED TAX:     FICA:     STATE TAX:      SDI:      VAC/HOL      H/W       PENSION

                                                                                              S                                                                   0
                                                                                                                                                                                                  -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:     DUES:      TRAV/SUBS.   SAVING:    OTHER*    TOTAL DEDUC:

                                                                                             O                                                                    0                                                                                                                                     -
                                                                                                                                                                                                                           FED TAX:     FICA:     STATE TAX:      SDI:      VAC/HOL      H/W       PENSION

                                                                                              S                                                                   0
                                                                                                                                                                                                  -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:     DUES:      TRAV/SUBS.   SAVING:    OTHER*    TOTAL DEDUC:

                                                                                             O                                                                    0                                                                                                                                     -
                                                                                                                                                                                                                           FED TAX:     FICA:     STATE TAX:      SDI:      VAC/HOL      H/W       PENSION

                                                                                              S                                                                   0
                                                                                                                                                                                                  -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:     DUES:      TRAV/SUBS.   SAVING:    OTHER*    TOTAL DEDUC:

                                                                                             O                                                                    0                                                                                                                                     -
                                                                                                                                                                                                                           FED TAX:     FICA:     STATE TAX:      SDI:      VAC/HOL      H/W       PENSION

                                                                                              S                                                                   0
                                                                                                                                                                                                  -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:     DUES:      TRAV/SUBS.   SAVING:    OTHER*    TOTAL DEDUC:

                                                                                             O                                                                    0                                                                                                                                     -
                                                                                                                                                                                                                           FED TAX:     FICA:     STATE TAX:      SDI:      VAC/HOL      H/W       PENSION

                                                                                              S                                                                   0
                                                                                                                                                                                                  -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:     DUES:      TRAV/SUBS.   SAVING:    OTHER*    TOTAL DEDUC:

                                                                                             O                                                                    0                                                                                                                                     -
                                                                                                                                                                                                                           FED TAX:     FICA:     STATE TAX:      SDI:      VAC/HOL      H/W       PENSION

                                                                                              S                                                                   0
                                                                                                                                                                                                  -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:     DUES:      TRAV/SUBS.   SAVING:    OTHER*    TOTAL DEDUC:

                                                                                             O                                                                    0                                                                                                                                     -
                                                                                                                                           Total Hours=                     Wages =
                                                                                                                                                                 83.50                   3,862.00
                                                                                                                                                                                                                           I FYOU WANT TO KEEP USING YOUR OWN FORM
                                                                                                                                                                                                                           YOU MAY HAND WRITE THIS INFORMATION
S = STRAIGHT TIME                                                               *OTHER - Any other deductions, contributions and/or payments or not included or required by prevailing
O = OVER TIME                                                                            wage determination must be separately listed. Use extra sheet(s) if necessary
SDI = STATE DISABILITY INSURANCE




               ref: DIR-A-1-131
                                                                                                                               PAYROLL REPORTING FORM
                                                                                                                                                                                                                                                                                                                  PAGE 3 OF 6




NAME OF CONTRACTOR OR SUBCONTRACTOR                                                                              ADDRESS                                                                                                                                                               CONTRACTOR'S LICENSE NO:




PAYROLL NO.                                          FOR WEEK ENDING                                             PROJECT NAME AND LOCATION                                                                                                                                             PROJECT/CONTRACT NO.




                              (1)         (2)                                 (3)                                               (4)                              (5)            (6)                     (7)                                                          (8)                                               (9)        (10)
                                                     (a)   (b)                                                             DAY AND DATE




                                                                                              O.T. OR S.T.
                                       WITHHOLDING
                                       EXEMPTIONS



                                                           RACIAL CODE
                NAME, ADDRESS, AND                                                                           M     T       W     T     F       S      S        TOTAL          RATE          GROSS              GROSS                                                                                                NET WAGE
                                          NO. OF

              SOCIAL SECURITY NUMBER                                         WORK                                                                             HOURS          OF PAY        AMOUNT             AMOUNT                            DEDUCTION, CONTRIBUTIONS AND PAYMENTS                                 PAID       CHECK
                     OF EMPLOYEE                     M/F                 CLASSIFICATION                                                                      (This Job)                    EARNED              EARNED                                                                                               FOR WEEK      NO.
                                                                                                                       HOURS WORKED EACH DAY
                                                                                                                                                                                           (This Job)         (ALL JOBS)

                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                           Total Hours=                   Wages =
                                                                                                                                                                   -                     0.00

S = STRAIGHT TIME                                                               *OTHER - Any other deductions, contributions and/or payments or not included or required by prevailing
O = OVER TIME                                                                            wage determination must be separately listed. Use extra sheet(s) if necessary
SDI = STATE DISABILITY INSURANCE




               ref: DIR-A-1-131
                                                                                                                               PAYROLL REPORTING FORM
                                                                                                                                                                                                                                                                                                                  PAGE 4 OF 6




NAME OF CONTRACTOR OR SUBCONTRACTOR                                                                              ADDRESS                                                                                                                                                               CONTRACTOR'S LICENSE NO:




PAYROLL NO.                                          FOR WEEK ENDING                                             PROJECT NAME AND LOCATION                                                                                                                                             PROJECT/CONTRACT NO.




                              (1)         (2)                                 (3)                                               (4)                              (5)            (6)                     (7)                                                          (8)                                               (9)        (10)
                                                     (a)   (b)                                                             DAY AND DATE




                                                                                              O.T. OR S.T.
                                       WITHHOLDING
                                       EXEMPTIONS



                                                           RACIAL CODE
                NAME, ADDRESS, AND                                                                           M     T       W     T     F       S      S        TOTAL          RATE          GROSS              GROSS                                                                                                NET WAGE
                                          NO. OF

              SOCIAL SECURITY NUMBER                                         WORK                                                                             HOURS          OF PAY        AMOUNT             AMOUNT                            DEDUCTION, CONTRIBUTIONS AND PAYMENTS                                 PAID       CHECK
                     OF EMPLOYEE                     M/F                 CLASSIFICATION                                                                      (This Job)                    EARNED              EARNED                                                                                               FOR WEEK      NO.
                                                                                                                       HOURS WORKED EACH DAY
                                                                                                                                                                                           (This Job)         (ALL JOBS)

                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                           Total Hours=                   Wages =
                                                                                                                                                                   -                     0.00

S = STRAIGHT TIME                                                               *OTHER - Any other deductions, contributions and/or payments or not included or required by prevailing
O = OVER TIME                                                                            wage determination must be separately listed. Use extra sheet(s) if necessary
SDI = STATE DISABILITY INSURANCE




               ref: DIR-A-1-131
                                                                                                                               PAYROLL REPORTING FORM
                                                                                                                                                                                                                                                                                                                  PAGE 5 OF 6




NAME OF CONTRACTOR OR SUBCONTRACTOR                                                                              ADDRESS                                                                                                                                                               CONTRACTOR'S LICENSE NO:




PAYROLL NO.                                          FOR WEEK ENDING                                             PROJECT NAME AND LOCATION                                                                                                                                             PROJECT/CONTRACT NO.




                              (1)         (2)                                 (3)                                               (4)                              (5)            (6)                     (7)                                                          (8)                                               (9)        (10)
                                                     (a)   (b)                                                             DAY AND DATE




                                                                                              O.T. OR S.T.
                                       WITHHOLDING
                                       EXEMPTIONS



                                                           RACIAL CODE
                NAME, ADDRESS, AND                                                                           M     T       W     T     F       S      S        TOTAL          RATE          GROSS              GROSS                                                                                                NET WAGE
                                          NO. OF

              SOCIAL SECURITY NUMBER                                         WORK                                                                             HOURS          OF PAY        AMOUNT             AMOUNT                            DEDUCTION, CONTRIBUTIONS AND PAYMENTS                                 PAID       CHECK
                     OF EMPLOYEE                     M/F                 CLASSIFICATION                                                                      (This Job)                    EARNED              EARNED                                                                                               FOR WEEK      NO.
                                                                                                                       HOURS WORKED EACH DAY
                                                                                                                                                                                           (This Job)         (ALL JOBS)

                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                           Total Hours=                   Wages =
                                                                                                                                                                   -                     0.00

S = STRAIGHT TIME                                                               *OTHER - Any other deductions, contributions and/or payments or not included or required by prevailing
O = OVER TIME                                                                            wage determination must be separately listed. Use extra sheet(s) if necessary
SDI = STATE DISABILITY INSURANCE




               ref: DIR-A-1-131
                                                                                                                               PAYROLL REPORTING FORM
                                                                                                                                                                                                                                                                                                                  PAGE 6 OF 6




NAME OF CONTRACTOR OR SUBCONTRACTOR                                                                              ADDRESS                                                                                                                                                               CONTRACTOR'S LICENSE NO:




PAYROLL NO.                                          FOR WEEK ENDING                                             PROJECT NAME AND LOCATION                                                                                                                                             PROJECT/CONTRACT NO.




                              (1)         (2)                                 (3)                                               (4)                              (5)            (6)                     (7)                                                          (8)                                               (9)        (10)
                                                     (a)   (b)                                                             DAY AND DATE




                                                                                              O.T. OR S.T.
                                       WITHHOLDING
                                       EXEMPTIONS



                                                           RACIAL CODE
                NAME, ADDRESS, AND                                                                           M     T       W     T     F       S      S        TOTAL          RATE          GROSS              GROSS                                                                                                NET WAGE
                                          NO. OF

              SOCIAL SECURITY NUMBER                                         WORK                                                                             HOURS          OF PAY        AMOUNT             AMOUNT                            DEDUCTION, CONTRIBUTIONS AND PAYMENTS                                 PAID       CHECK
                     OF EMPLOYEE                     M/F                 CLASSIFICATION                                                                      (This Job)                    EARNED              EARNED                                                                                               FOR WEEK      NO.
                                                                                                                       HOURS WORKED EACH DAY
                                                                                                                                                                                           (This Job)         (ALL JOBS)

                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                                                                                                           FED TAX:     FICA:      STATE TAX:      SDI:      VAC/HOL      H/W        PENSION

                                                                                              S                                                                  0
                                                                                                                                                                                                  -                                                                                                                          -
                                                                                                                                                                                                                           TRAING.:   FUND AMD:      DUES:      TRAV/SUBS.   SAVING:    OTHER*     TOTAL DEDUC:

                                                                                             O                                                                   0                                                                                                                                        -
                                                                                                                                           Total Hours=                   Wages =
                                                                                                                                                                   -                     0.00

S = STRAIGHT TIME                                                               *OTHER - Any other deductions, contributions and/or payments or not included or required by prevailing
O = OVER TIME                                                                            wage determination must be separately listed. Use extra sheet(s) if necessary
SDI = STATE DISABILITY INSURANCE




               ref: DIR-A-1-131

								
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