*FRINGE BENEFITS EXPLANATION (P):
Bona fide benefits paid to approved plans, funds or programs, except those required by Federal or State
Law (unemployment tax, worker's compensation, income taxes, etc.).
Please specify the type of benefits provided:
1) Medical or hospital care Blue Cross 4) Disability _
2) Pension or retirement 5) Vacation, holiday _
3) Life Insurance Utopia 6) Other (please specify) _
CERTIFIED STATEMENT OF COMPLIANCE
For the week ending date of 9/26/09
-----------'
I, Robert Craft
of XYZ Corporation
, (hereafter known as
Employer) in my capacity as Owner (title) do hereby certify and state:
Section A:
I. All persons employed on said project have been paid the full weekly wages earned by them during
the week in accordance with Connecticut General Statutes, section 31-53, as amended. Further, I
hereby certify and state the following:
a) The records submitted are true and accurate;
b) The rate of wages paid to each mechanic, laborer or workman and the amount of payment or
contributions paid or payable on behalf of each such employee to any e'mployee welfare fund, as
defined in Connecticut General Statutes, section 31-53 (h), are not less than the prevailing rate
of wages and the amount of payment or contributions paid or payable on behalf of each such
employee to any employee'welfare fund, as determined by the Labor Commissioner pursuant to
subsection Connecticut General Statutes, section 31-53 (d), and said wages and benefits are not
less than those which may also be required by contract;
c) The Employer has complied with all of the provisions in Connecticut General Statutes,
section 31-53 (and Section 31-54 if applicable for state highway construction);
d) Each such employee of the Employer is covered by a worker's compensation insurance
policy for the duration of his employment which proof of coverage has been provided to the
contracting agency;
e) The Employer does not receive kickbacks, which means any money, fee, commission, credit,
gift, gratuity, thing of value, or compensation of any kind which is provided directly or
indirectly, to any prime contractor, prime contractor employee, subcontractor, or subcontractor
employee for the purpose of improperly obtaining or rewarding favorable treatment in
connection with a prime contract or in connection with a prime contractor in connection with a
subcontractor relating to a prime contractor; and
f) The Employer is aware that filing a certified payroll which he knows to be false is a class D
felony for which the employer may be fined up to five thousand dollars, imprisoned for up to
five years or both.
2. OSHA-The employer shall affix a copy of the construction safety course, program or
training completion document to the certified payroll required to be submitted to the contracting
agency for this project on which such employee's name first appears.
~~~
(Signature) ,
ow~
(Title)
/o/~-) t/ Cj
Submitte6 on (.Date)
Section B: Applies to CONNDOT Projects ONLY
That pursuant to CONNDOT contract requirements for reporting purposes only, all employees
listed under Section B who performed work on this project are not covered under the prevailing
wageRquirements defined in Connecticut General Statutes Section 31-53.
o u/I.../e; "-
(Title)
Note: CTDOL will assume all hours worked were performed under Section A unless clearly
delineated as Section B WWS-CP I as such. Should an employee perform work under both
Section A and Section B, the hours worked and wages paid must be segregated for reporting
purposes.
***THIS IS A PUBLIC DOCUMENT***
***DO NOT INCLUDE SOCIAL SECURITY NUMBERS***