Free Illinois Certified Transcript Of Payroll PDF Download

State of Illinois

Illinois Department of Labor

IDOL Case File Number:

Certified Transcript of Payroll

Print Form

Please Note: The submission of falsified payroll records is a criminal offense.

Payroll Date:

Contractor and/or Subcontractor

Public Body Information

(Contract Number) (Project Number)

(Project Location)

(State)

(Company Name) (Contact Name) (Street Address) (City)

(Zipcode) (Telephone Number)

(State)

(Public Body Name) (Contact Name)

(Street Address) (City)

(Zipcode) (Telephone Number)

Report Hours for Each Day, Including Overtime Hours, List Hourly Prevailing Wage Rate and Hourly Fringe Benefits Allotments.

Worker Name, Address

* Hours worked each day

Total Hrs Each

Total OT

Hourly Wage

OT Wage

Per Pay Period

SSN & Telephone Number

SUN MON TUE WED THR FRI SAT

PW N

PW and Reg.

Hours

Rate

Rate

Gross

Net

Labor Classification

Hourly Fringe Benefit: Pension: Health/Welfare: Vacation: Training:

PW N

Labor Classification

Hourly Fringe Benefit: Pension: Health/Welfare: Vacation: Training:

PW N

Labor Classification

Hourly Fringe Benefit: Pension: Health/Welfare: Vacation: Training:

PW N

Labor Classification

Hourly Fringe Benefit: Pension: Health/Welfare: Vacation: Training:

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IL452CM02

*PW - Prevailing Hours Worked *N - Non Prevailing Hours Worked

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State of Illinois

Illinois Department of Labor

Certified Transcript of Payroll

Instructions:

Fringe benefits (health insurance, pension, vacation, and training) must be paid, if it is required for the work classification, regardless of your union or nonunion status.

We give you credit for health insurance paid (if any) and ERISA approved pension plan (if any) and training if your employees are in a BAT approved program.

If the fringe benefit rate is paid into a fund, please note by placing the letter “F” behind the fringe benefit rate; if the fringe benefit rate is included on an employee's payroll check, please note by placing the letter “E” behind the fringe benefit rate.

On the back of this form please list all subcontractors, independent contractors and owner operator's your company used on this project. If you wish information regarding coverage of the Act, please visit our web site at www.state.il.us/agency/idol/ or call 217-782-1710.

IL452CM02