This form contains 554 fields organized into 25 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Benefit Program Row 1
Row 1 - Program Title / Classification / Worker	Text	Enter the benefit program title, classification title, or the individual workers covered by this benefit for row 1. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 1 - Health/Welfare (per hour)	Number	Enter the amount contributed per hour to health/welfare benefits for this program on row 1. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 1 - Vacation/Holiday (per hour)	Number	Enter the amount contributed per hour to vacation or holiday benefits for this program on row 1. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 1 - Apprenticeship/Training (per hour)	Number	Enter the amount contributed per hour to apprenticeship or training benefits for this program on row 1. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 1 - Pension (per hour)	Number	Enter the amount contributed per hour to pension benefits for this program on row 1. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 1 - Other Benefit Type and Amount	Text	Describe any other benefit type(s) and provide the associated amount(s) per hour (e.g., long‑term disability, life insurance) for this program on row 1. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 1 - Fringe Benefit Fund/Plan Administrator Name	Text	Enter the name of the fringe benefit fund, plan, or program administrator associated with this benefit on row 1. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 1 - Fringe Benefit Fund/Plan Administrator Address	Text	Enter the address of the fringe benefit fund, plan, or program administrator for this benefit on row 1. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 60 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 1 - USDOL Benefit Plan Filing Number / EIN	Text	Enter the USDOL benefit plan filing number or the employer identification number (EIN) for this benefit plan on row 1. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 20 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 1 - Third‑Party Trustee or Contact Person	Text	Enter the name (and optionally contact details) of the third‑party trustee and/or contract contact person for this benefit on row 1. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 40 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Benefit Program Row 10
Row 10 - Program Title / Classification / Individual Workers	Text	Enter the program title, classification title, or the name(s) of individual workers covered by this benefit program. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 10 - Name & Address of Fringe Benefit Fund / Plan Administrator	Text	Enter the full name and mailing address of the fringe benefit fund, plan, or program administrator associated with this benefit program. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 60 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 10 - USDOL Benefit Plan Filing Number / EIN	Text	Enter the USDOL benefit plan filing number or the employer identification number (EIN) associated with this benefit plan. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 20 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 10 - Health/Welfare Amount (per hour)	Number	Enter the amount contributed per hour toward health and welfare benefits for this program. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 10 - Vacation/Holiday Amount (per hour)	Number	Enter the amount contributed per hour toward vacation or holiday benefits for this program. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 10 - Apprenticeship/Training Amount (per hour)	Number	Enter the amount contributed per hour toward apprenticeship or training benefits for this program. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 10 - Pension Amount (per hour)	Number	Enter the amount contributed per hour toward pension benefits for this program. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 10 - Other Benefit Type (description)	Text	Provide the name or a brief description of any other benefit type being reported (for example, training, long-term disability, or life insurance). Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 10 - Third-Party Trustee or Contract Person	Text	Enter the name and contact information of the third-party trustee or contract person for this benefit program. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 40 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 10 - Other Benefit Amount (per hour)	Number	Enter the amount contributed per hour for the other benefit listed in the adjacent column. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Benefit Program Row 11
Row 11 - Program Title / Classification	Text	Enter the name of the benefit program, classification title, or individual worker title for row 11. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 11 - USDOL Benefit Plan Filing Number / EIN	Text	Enter the USDOL benefit plan filing number or the employer identification number (EIN) associated with this fringe benefit program for row 11. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 60 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 11 - Third‑Party Trustee or Contact Person	Text	Enter the name of the third‑party trustee or the contact person responsible for this fringe benefit program for row 11. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 20 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 11 - Health/Welfare amount per hour	Number	Enter the amount contributed per hour toward health and welfare benefits for this program on row 11. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 11 - Vacation/Holiday amount per hour	Number	Enter the amount contributed per hour toward vacation or holiday benefits for this program on row 11. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 11 - Apprenticeship/Training amount per hour	Number	Enter the amount contributed per hour toward apprenticeship or training benefits for this program on row 11. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 11 - Pension amount per hour	Number	Enter the amount contributed per hour toward pension benefits for this program on row 11. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 11 - Other benefit amount per hour	Number	Enter the amount contributed per hour for other benefit types (e.g., training, long‑term disability, life insurance) associated with this program on row 11. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 11 - Additional information / Notes	Text	Enter any additional identifying information or notes related to this fringe benefit program for row 11. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 40 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 11 - Fringe Benefit Fund / Plan Administrator Name & Address	Text	Enter the name and full mailing address of the fringe benefit fund, plan, or program administrator for row 11. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Benefit Program Row 12
Row 12 - Program Title / Classification / Worker	Text	Enter the program title, classification title, or individual worker name for benefit program row 12. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 12 - Fund / Plan Administrator Name & Address	Text	Enter the name and full mailing address of the fringe benefit fund, plan, or program administrator for benefit program row 12. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 60 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 12 - USDOL Benefit Plan Filing Number / EIN	Text	Enter the USDOL benefit plan filing number or employer identification number (EIN) associated with this fringe benefit for row 12. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 20 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 12 - Health/Welfare Contribution	Number	Enter the contribution for Health/Welfare for benefit program row 12. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 12 - Vacation/Holiday Contribution	Number	Enter the contribution for Vacation/Holiday for benefit program row 12. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 12 - Apprenticeship/Training Contribution	Number	Enter the contribution for Apprenticeship/Training for benefit program row 12. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 12 - Pension Contribution	Number	Enter the contribution for Pension for benefit program row 12. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 12 - Other Benefit Amount	Number	Enter the contribution amount for any other benefit type for benefit program row 12. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 12 - Third‑Party Trustee or Contact Person	Text	Enter the name and contact information of the third‑party trustee or contract person associated with this fringe benefit for benefit program row 12. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 40 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 12 - Other Benefit Type and Details	Text	Describe the other fringe benefit (for example, training, long-term disability or life insurance) and provide any relevant details for benefit program row 12. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Benefit Program Row 13
Row 13 - Program Title / Classification	Text	Enter the program title, classification title, or individual worker name for benefit program listed on row 13. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 13 - USDOL Benefit Plan Filing Number / EIN	Text	Enter the USDOL benefit plan filing number or the Employer Identification Number (EIN) for the fund or plan listed on row 13. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 60 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 13 - Third‑Party Trustee or Contract Person	Text	Enter the name of the third‑party trustee or contract person responsible for the benefit program on row 13. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 20 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 13 - Health/Welfare	Number	Enter the amount contributed per hour by the employer for Health/Welfare for the benefit program on row 13. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 13 - Vacation/Holiday	Number	Enter the amount contributed per hour by the employer for Vacation/Holiday benefits for the benefit program on row 13. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 13 - Apprenticeship/Training	Number	Enter the amount contributed per hour by the employer for Apprenticeship/Training for the benefit program on row 13. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 13 - Pension	Number	Enter the amount contributed per hour by the employer for Pension for the benefit program on row 13. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 13 - Other Benefit Amount	Number	Enter the amount contributed per hour by the employer for any other listed benefit type for the benefit program on row 13. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 13 - Trustee / Contact Info	Text	Enter short contact information (for example, phone number or email) for the third‑party trustee or contract person for the benefit program on row 13. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 40 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 13 - Name & Address of Fringe Benefit Fund / Plan Administrator	Text	Enter the full name and mailing address of the fringe benefit fund, plan, or program administrator associated with the benefit program on row 13. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Benefit Program Row 14
Row 14 - Program Title / Classification	Text	Enter the program title, classification title, or individual worker job title for the benefit program on row 14. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 14 - USDOL Benefit Plan Filing Number / EIN	Text	Enter the USDOL benefit plan filing number or the employer identification number (EIN) associated with the benefit program on row 14. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 60 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 14 - Third‑Party Trustee or Contract Person	Text	Enter the name and contact details of the third‑party trustee or contract person responsible for administering the benefit program on row 14. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 20 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 14 - Health/Welfare (Per Hour)	Number	Enter the amount contributed per hour toward health and welfare benefits for the benefit program on row 14. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 14 - Vacation/Holiday (Per Hour)	Number	Enter the amount contributed per hour toward vacation or holiday benefits for the benefit program on row 14. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 14 - Apprenticeship/Training (Per Hour)	Number	Enter the amount contributed per hour toward apprenticeship or training benefits for the benefit program on row 14. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 14 - Pension (Per Hour)	Number	Enter the amount contributed per hour toward pension benefits for the benefit program on row 14. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 14 - Other Benefit Type and Amount	Text	Provide the other benefit type and any related amount or brief details (for example, training, long‑term disability, or life insurance) for the benefit program on row 14. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 14 - Additional Identifier / Notes	Text	Enter any additional identifier, code, phone number, or brief note related to the benefit program on row 14. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 40 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 14 - Fringe Benefit Fund / Plan Name & Address	Text	Enter the full name and mailing address of the fringe benefit fund, plan, or program administrator associated with the benefit program on row 14. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Benefit Program Row 15
Row 15 Program Title / Classification	Text	Enter the program title, job classification title, or individual worker description for benefit program row 15. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 15 Fringe Benefit Fund Name & Address	Text	Provide the name and full address of the fringe benefit fund, plan, or program administrator associated with benefit program row 15. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 60 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 15 USDOL Benefit Plan Filing No. / EIN	Text	Enter the USDOL benefit plan filing number or the employer/plan EIN for benefit program row 15. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 20 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 15 Health/Welfare Amount	Number	Enter the amount contributed per hour to the Health/Welfare benefit for benefit program row 15. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 15 Vacation/Holiday Amount	Number	Enter the amount contributed per hour to the Vacation/Holiday benefit for benefit program row 15. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 15 Apprenticeship/Training Amount	Number	Enter the amount contributed per hour to the Apprenticeship/Training benefit for benefit program row 15. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 15 Pension Amount	Number	Enter the amount contributed per hour to the Pension benefit for benefit program row 15. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 15 Other Benefit Amount	Number	Enter the amount contributed per hour for any other benefit type listed for benefit program row 15. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 15 Third-Party Trustee / Contact	Text	Provide the name of the third-party trustee or contact person (and any relevant contact details) for benefit program row 15. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 40 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 15 Other Benefit Type / Description	Text	Describe the other benefit type(s) (for example, training, long-term disability, life insurance) associated with the amount listed for benefit program row 15. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Benefit Program Row 16
Row 16 - Program Title / Classification	Text	Enter the program title, classification title, or name of the individual workers for this benefit row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 16 - Administrator Name & Address	Text	Enter the full name and mailing address of the fringe benefit fund, plan, or program administrator for this row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 60 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 16 - USDOL Benefit Plan Filing Number / EIN	Text	Enter the USDOL benefit plan filing number or employer identification number (EIN) for the benefit plan referenced in this row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 20 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 16 - Health/Welfare Contribution	Number	Enter the amount contributed per hour for health and welfare for this benefit row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 16 - Vacation/Holiday Contribution	Number	Enter the amount contributed per hour for vacation/holiday for this benefit row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 16 - Apprenticeship/Training Contribution	Number	Enter the amount contributed per hour for apprenticeship or training for this benefit row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 16 - Pension Contribution	Number	Enter the amount contributed per hour for pension for this benefit row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 16 - Other Benefit Type and Amount	Text	Describe any other benefit type(s) for this row (e.g., training, long-term disability or life insurance) and provide the associated amount information. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 16 - Third-Party Trustee / Contract Person	Text	Enter the name of the third-party trustee or contract person/company responsible for administering the benefit for this row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 40 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 16 - Administrator Name (short)	Text	Enter a short name or identifier for the fringe benefit fund, plan, or program administrator associated with this row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Benefit Program Row 17
Row 17 - Program Title / Classification	Text	Enter the program title, worker classification, or individual worker name(s) for this benefit row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 17 - USDOL Plan Filing Number / EIN	Text	Enter the USDOL benefit plan filing number or the employer identification number (EIN) for the listed fund or plan. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 60 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 17 - Third‑Party Trustee or Contact Person	Text	Enter the name and contact information of the third‑party trustee or contract person responsible for administering this benefit, if applicable. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 20 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 17 - Health/Welfare Amount	Number	Enter the amount contributed per hour for health and welfare benefits for this program or classification. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 17 - Vacation/Holiday Amount	Number	Enter the amount contributed per hour for vacation or holiday benefits for this program or classification. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 17 - Apprenticeship/Training Amount	Number	Enter the amount contributed per hour for apprenticeship or training benefits for this program or classification. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 17 - Pension Amount	Number	Enter the amount contributed per hour for pension benefits for this program or classification. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 17 - Other Benefit Type and Amount	Text	Provide the other benefit type(s) and any associated amount or brief details (for example, training, long‑term disability, life insurance) for this row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 17 - Additional Trustee / Contact Info	Text	Provide any additional short identifier or contact detail related to the trustee, contract person, or plan administrator (for example, phone extension or brief note). Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 40 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 17 - Name & Address of Benefit Fund/Administrator	Text	Enter the name and full address of the fringe benefit fund, plan, or program administrator associated with this benefit. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Benefit Program Row 18
Row 18 - Program Title / Classification	Text	Enter the program name, classification title, or the name of the individual workers to which this benefit row applies. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 18 - Pension (Amount Contributed Per Hour)	Number	Enter the hourly pension contribution amount for this program/classification as a numeric value. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 18 - Health/Welfare (Amount Contributed Per Hour)	Number	Enter the hourly health/welfare contribution amount for this program/classification as a numeric value. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 18 - Vacation/Holiday (Amount Contributed Per Hour)	Number	Enter the hourly vacation/holiday contribution amount for this program/classification as a numeric value. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 18 - Apprenticeship/Training (Amount Contributed Per Hour)	Number	Enter the hourly apprenticeship or training contribution amount for this program/classification as a numeric value. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 18 - Other Benefit Type and Amount	Text	Provide the other benefit type (for example, training, long‑term disability, life insurance) and any associated amount or notes for this program/classification. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 18 - Name & Address of Fringe Benefit Fund / Plan Administrator	Text	Enter the full name and mailing address of the fringe benefit fund, plan, or program administrator for this benefit row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 18 - USDOL Benefit Plan Filing Number / EIN	Text	Enter the USDOL benefit plan filing number or employer identification number (EIN) associated with this benefit plan. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 60 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 18 - Third‑Party Trustee / Contract Person	Text	Enter the name or contact person for any third‑party trustee or contract person responsible for this benefit program. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 20 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 18 - Additional Notes / Identifier	Text	Use this field for any additional identifier, notes, or supplemental contact information relevant to this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 40 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Benefit Program Row 2
Row 2 - Program Title / Classification / Individual Workers	Text	Enter the program title, classification title, or description of the individual workers covered by this benefit program in row 2. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 2 - Health/Welfare Amount Per Hour	Number	Enter the amount contributed per hour to the Health/Welfare benefit for this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 2 - Vacation/Holiday Amount Per Hour	Number	Enter the amount contributed per hour to the Vacation/Holiday benefit for this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 2 - Apprenticeship/Training Amount Per Hour	Number	Enter the amount contributed per hour to the Apprenticeship/Training benefit for this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 2 - Pension Amount Per Hour	Number	Enter the amount contributed per hour to the Pension benefit for this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 2 - Other Benefit Type and Details	Text	Provide the other benefit type and any relevant details (for example training, long‑term disability, life insurance) for this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 2 - Other Benefit Amount Per Hour	Number	Enter the amount contributed per hour for the other benefit listed in the adjacent column for this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 2 - Name & Address of Fringe Benefit Fund / Plan / Administrator	Text	Enter the full name and mailing address of the fringe benefit fund, plan, or program administrator associated with this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 60 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 2 - USDOL Benefit Plan Filing Number / EIN	Number	Provide the USDOL benefit plan filing number or employer identification number (EIN) associated with this benefit plan for this row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 20 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 2 - Third‑Party Trustee / Contract Person	Text	Enter the name of the third‑party trustee or contract person (and contact information if applicable) responsible for administering or holding the benefit funds for this row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 40 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Benefit Program Row 3
Row 3 Program / Classification Title	Text	Enter the benefit program title, job classification, or individual worker names associated with this Row 3 entry. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 3 Health/Welfare Amount per Hour	Number	Enter the amount contributed per hour to Health/Welfare for this Row 3 benefit program. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 3 Vacation/Holiday Amount per Hour	Number	Enter the amount contributed per hour to Vacation/Holiday for this Row 3 benefit program. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 3 Apprenticeship/Training Amount per Hour	Number	Enter the amount contributed per hour to Apprenticeship or Training for this Row 3 benefit program. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 3 Pension Amount per Hour	Number	Enter the amount contributed per hour to Pension for this Row 3 benefit program. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 3 Other Benefit Type and Amount	Text	Provide the other benefit type (e.g., training, long‑term disability, life ins.) and the amount contributed per hour for this Row 3 entry. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 3 Fund / Plan Administrator Name	Text	Enter the name of the fringe benefit fund, plan, or program administrator for this Row 3 benefit entry. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 3 Fund / Plan Administrator Address	Text	Provide the mailing address (street, city, state, ZIP) of the fringe benefit fund, plan, or program administrator for Row 3. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 60 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 3 USDOL Benefit Plan Filing Number / EIN	Number	Enter the USDOL benefit plan filing number or employer identification number (EIN) associated with the Row 3 benefit plan. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 20 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 3 Third-Party Trustee or Contract Person	Text	Enter the name and contact information of any third‑party trustee or contract person responsible for the Row 3 benefit plan. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 40 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Benefit Program Row 4
Row 4 Program/Classification or Individual Worker	Text	Enter the benefit program title, classification title, or individual worker designation for row 4. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 4 Health & Welfare Amount per Hour	Number	Enter the amount contributed per hour to health and welfare for this program/classification in row 4. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 4 Vacation/Holiday Amount per Hour	Number	Enter the amount contributed per hour toward vacation or holiday benefits for row 4. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 4 Apprenticeship/Training Amount per Hour	Number	Enter the amount contributed per hour toward apprenticeship or training for row 4. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 4 Pension Amount per Hour	Number	Enter the amount contributed per hour toward pension benefits for row 4. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 4 Other Benefit Type	Text	Enter the name or brief description of any other fringe benefit type (for example, training, long-term disability, or life insurance) for row 4. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 4 Other Benefit Amount per Hour	Number	Enter the amount contributed per hour for the other benefit listed in row 4. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 4 Fringe Benefit Fund/Plan Administrator Name & Address	Text	Enter the name and full mailing address of the fringe benefit fund, plan, or program administrator associated with row 4. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 60 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 4 USDOL Benefit Plan Filing Number / EIN	Number	Enter the USDOL benefit plan filing number or employer identification number (EIN) for the plan listed in row 4. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 20 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 4 Third-Party Trustee or Contract Person	Text	Enter the name (and contact information if applicable) of the third-party trustee or contract person responsible for administering the benefit in row 4. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 40 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Benefit Program Row 5
Row 5 - Program Title / Classification / Workers	Text	Enter the program title, classification title, or description of the individual workers covered by this benefit program. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 5 - USDOL Benefit Plan Filing Number / EIN	Number	Enter the USDOL benefit plan filing number or the employer identification number (EIN) associated with this benefit plan. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 60 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 5 - Third‑Party Trustee or Contract Person	Text	Enter the name of the third‑party trustee or contract person responsible for the benefit plan and any identifying details. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 20 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 5 - Health/Welfare Amount	Number	Enter the amount contributed per hour to health and welfare for this benefit program. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 5 - Vacation/Holiday Amount	Number	Enter the amount contributed per hour to vacation or holiday benefits for this benefit program. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 5 - Apprenticeship/Training Amount	Number	Enter the amount contributed per hour to apprenticeship or training for this benefit program. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 5 - Pension Amount	Number	Enter the amount contributed per hour to pension benefits for this benefit program. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 5 - Other Benefit Type and Amount	Text	Enter any other benefit type and a brief description or the hourly amount (for example, training, long‑term disability, or life insurance). Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 5 - Third‑Party Trustee Additional Info	Text	Enter any additional identifying information for the third‑party trustee or contract person such as phone number, title, or other identifier. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 40 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 5 - Name & Address of Benefit Fund / Administrator	Text	Provide the name and full address of the fringe benefit fund, plan, or program administrator for this benefit. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Benefit Program Row 6
Row 6 Program Title / Classification	Text	Enter the program or classification title or the individual worker classification that identifies this benefit program for row 6. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 6 Name & Address of Fringe Benefit Fund / Administrator	Text	Provide the full name and mailing address of the fringe benefit fund, plan, or program administrator associated with the benefit program on row 6. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 60 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 6 USDOL Benefit Plan Filing Number / EIN	Text	Enter the USDOL benefit plan filing number or Employer Identification Number (EIN) associated with the benefit program on row 6, if applicable. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 20 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 6 Health/Welfare Amount per Hour	Number	Enter the amount contributed per hour for health/welfare for the benefit program on row 6. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 6 Vacation/Holiday Amount per Hour	Number	Enter the amount contributed per hour for vacation/holiday for the benefit program on row 6. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 6 Apprenticeship/Training Amount per Hour	Number	Enter the amount contributed per hour for apprenticeship or training for the benefit program on row 6. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 6 Other Benefit Type and Amount	Text	Describe any other benefit type (e.g., training, long‑term disability or life insurance) and include the amount contributed per hour for the benefit program on row 6. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 6 Third-Party Trustee / Contract Person	Text	Enter the name (and, if desired, contact information) of any third‑party trustee or contract person responsible for administering this benefit program on row 6. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 40 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 6 Pension Amount per Hour	Number	Enter the amount contributed per hour for pension for the benefit program on row 6. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Benefit Program Row 7
Row 7 - Program Title / Classification / Individual Workers	Text	Enter the program name, worker classification title, or individual worker identifier for this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 4 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 7 - USDOL Benefit Plan Filing Number / EIN	Text	Enter the USDOL benefit plan filing number or the employer identification number (EIN) associated with this benefit plan for this row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 60 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 7 - Third-Party Trustee or Contract Person	Text	Enter the name or contact person (and optional contact details) for the third-party trustee or contract person responsible for this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 20 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 7 - Health/Welfare Amount per Hour	Number	Enter the amount contributed per hour for the Health/Welfare benefit for this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 7 - Vacation/Holiday Amount per Hour	Number	Enter the amount contributed per hour for the Vacation/Holiday benefit for this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 7 - Apprenticeship/Training Amount per Hour	Number	Enter the amount contributed per hour for the Apprenticeship/Training benefit for this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 7 - Pension Amount per Hour	Number	Enter the amount contributed per hour for the Pension benefit for this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 7 - Other Benefit Type and Amount	Text	Describe any other benefit type (for example, training, long‑term disability, or life insurance) and include the associated amount or note for this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 7 - Total Amount Contributed Per Hour	Number	Enter the total amount contributed per hour for all benefits combined for this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 40 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 7 - Name & Address of Fringe Benefit Fund / Plan Administrator	Text	Enter the full name and mailing address of the fringe benefit fund, plan, or program administrator associated with this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Benefit Program Row 8
Row 8 - Program Title / Classification / Individual Workers	Text	Enter the program title, classification title, or names of individual workers associated with this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 8 - USDOL Benefit Plan Filing Number / EIN	Text	Enter the U.S. Department of Labor benefit plan filing number or the employer identification number (EIN) associated with this benefit plan for Row 8. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 60 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 8 - Third-Party Trustee / Contract Person	Text	Enter the name of the third-party trustee or contract person responsible for administering or contracting this benefit plan for Row 8. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 20 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 8 - Health/Welfare Amount per Hour	Number	Enter the amount contributed per hour to Health/Welfare for this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 8 - Vacation/Holiday Amount per Hour	Number	Enter the amount contributed per hour to Vacation/Holiday for this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 8 - Apprenticeship/Training Amount per Hour	Number	Enter the amount contributed per hour to Apprenticeship/Training for this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 8 - Pension Amount per Hour	Number	Enter the amount contributed per hour to Pension for this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 8 - Other Benefit Type and Amount	Text	Specify any other benefit type (for example, training, long‑term disability, or life insurance) and the amount contributed per hour for this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 8 - Third-Party Trustee / Contract Person Phone	Text	Enter the contact phone number for the third-party trustee or contract person listed for this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 40 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 8 - Name & Address of Fringe Benefit Fund / Plan Administrator	Text	Enter the name and full address of the fringe benefit fund, plan, or program administrator for this benefit program row. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Benefit Program Row 9
Row 9 - Program Title / Classification	Text	Enter the program title, classification title, or individual worker description for benefit program in row 9. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 9 - Name & Address of Fringe Benefit Fund	Text	Provide the name and mailing address of the fringe benefit fund, plan, or program administrator for row 9. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 60 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 9 - USDOL Benefit Plan Filing Number / EIN	Text	Enter the USDOL benefit plan filing number or the employer identification number (EIN) associated with the fund for row 9. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 20 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 9 - Health/Welfare Amount (per hour)	Number	Enter the amount contributed per hour to health/welfare benefits for row 9. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 9 - Vacation/Holiday Amount (per hour)	Number	Enter the amount contributed per hour to vacation/holiday benefits for row 9. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 9 - Apprenticeship/Training Amount (per hour)	Number	Enter the amount contributed per hour to apprenticeship or training benefits for row 9. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 9 - Pension Amount (per hour)	Number	Enter the amount contributed per hour to pension benefits for row 9. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 9 - Other Benefit Type (description)	Text	Describe any other benefit type (for example, training, long‑term disability, or life insurance) provided for row 9. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 30 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 9 - Third‑Party Trustee / Contract Person	Text	Enter the name and contact information of any third‑party trustee or contract person associated with the benefit for row 9. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 40 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Row 9 - Other Benefit Amount (per hour)	Number	Enter the amount contributed per hour for the other benefit type listed in row 9. Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Contractor/Project Info
Contractor or Subcontractor Name	Text	Enter the full legal name of the contractor or subcontractor who pays or supervises the employees on this project. Max length: 30 characters
Project Name	Text	Enter the official name of the project where the employees are working. Max length: 30 characters
Project Location	Text	Enter the project location (city and state or full address) where the work is being performed. Max length: 30 characters
Payroll Period Start Date	Date	Enter the starting date of the payroll period.
Payroll Period End Date	Date	Enter the ending date of the payroll period.
Electronic Signature Checkbox
By checking this box and typing my name below, I am electronically signing this application	Checkbox	Check this box when you are electronically signing the form by typing your name below to confirm you understand the electronic signature has the same legal effect as a written signature.
Fringe Benefits - Paid in Cash Checkbox
Fringe Benefits Paid in Cash – Each laborer or mechanic has been paid in cash as shown on the payroll	Checkbox	Check this box when each laborer or mechanic listed on the payroll has been paid, in cash, an amount at least equal to the applicable basic hourly wage plus the required fringe benefit amount as indicated on the payroll.
Fringe Benefits - Paid to Approved Plans Checkbox
Fringe Benefits Paid to Approved Plans (4a)	Checkbox	Check this box if, in addition to basic hourly wage rates, payments of fringe benefits have been or will be made to approved plans, funds, or programs for the benefit of the employees and are reported in Section 4(c).
General
Su-date	Text	Max length: 5 characters
M-date	Text	Max length: 5 characters
Tu-date	Text	Max length: 5 characters
W-date	Text	Max length: 5 characters
Th-date	Text	Max length: 5 characters
F-date	Text	Max length: 5 characters
Sa-date	Text	Max length: 5 characters
1. Employee Name and Address_Row_1	Text
Job Title journeyman, foreman e.g., apprentice,_Row_1	Text
e.g., carpenter, mason, plumber Work Classification/ Occupational Category_Row_1	Text
Sex M=Male F=Female N=Non-Binary_Row_1	Text
Race - see Key below	Text
Ethnicity H=Hispanic N=Non- Hispanic_Row_1	Text
1 SuS Hrs	Text
1 MS Hrs	Text
1 TuS Hrs	Text
1 WS Hrs	Text
1SuS Hrs	Text
1 F-S Hrs	Text
1 Sa-S Hrs	Text
1 Total Hrs S	Text
1 Hourly Rate	Text
1 Su-O Hrs	Text
1 M-O Hrs	Text
1 Tu-O Hrs	Text
1 W-O Hrs	Text
1 TH-O Hrs	Text
1 F-O Hrs	Text
1 Sa-O Hrs	Text
1 Total Hrs -O	Text
1 Hourly Rate-O	Text
1 Gross Project Row1	Text
1 Gross Week	Text
1 FICA Row1	Text
1 Withholding Tax Row1	Text
1 State Tax	Text
OtherLabel1.0	Text
1 Other	Text
OtherLabel1.1	Text
1 Other 2	Text
1 Total Deductions	Text
1 Weekly Net Wages	Text
1 Total Fringe	Text
1. Employee Name and Address_Row_2	Text
Job Title journeyman, foreman e.g., apprentice,_Row_2	Text
e.g., carpenter, mason, plumber Work Classification/ Occupational Category_Row_2	Text
Sex M=Male F=Female N=Non-Binary_Row_2	Text
Race - see Key below	Text
Ethnicity H=Hispanic N=Non- Hispanic_Row_2	Text
2 Su-S Hrs	Text
2 M-S Hrs	Text
2 Tu-S Hrs	Text
2 W-S Hrs	Text
2 Th-S Hrs.1	Text
2 F-S Hrs	Text
2 Sa-S Hrs	Text
2 Total Hrs O2	Text
2 Hourly Rate-O	Text
2 Su-O Hrs	Text
2 M-O Hrs	Text
2 Tu-O Hrs	Text
2 W-O Hrs	Text
2 TH-O Hrs	Text
2 F-O Hrs	Text
2 Sa-O Hrs	Text
2 Total Hrs -O	Text
2 Hourly Rate-O	Text
2 Gross Project Row1	Text
2 Gross Week	Text
2 FICA Row1	Text
2 Withholding Tax Row1	Text
2 State Tax	Text
2 Other	Text
2 Other 2	Text
2 Total Deductions	Text
2 Weekly Net Wages	Text
2 Total Fringe	Text
1. Employee Name and Address_Row_3	Text
Job Title journeyman, foreman e.g., apprentice,_Row_3	Text
e.g., carpenter, mason, plumber Work Classification/ Occupational Category_Row_3	Text
Sex M=Male F=Female N=Non-Binary_Row_3	Text
Race - see Key below	Text
Ethnicity H=Hispanic N=Non- Hispanic_Row_3	Text
9 SuS Hrs	Text
3 MS Hrs	Text
9 TuS Hrs	Text
3 WS Hrs	Text
3 ThS Hrs	Text
3 F-S Hrs	Text
3 Sa-S Hrs	Text
3 Total Hrs S	Text
9 Hourly Rate	Text
3 Su-O Hrs	Text
3 M-O Hrs	Text
3 Tu-O Hrs	Text
3 W-O Hrs	Text
3 TH-O Hrs	Text
3 F-O Hrs	Text
3 Sa-O Hrs	Text
3 Total Hrs -O	Text
1 Hourly Rate-O	Text
3 Gross Project Row1	Text
3 Gross Week	Text
3FICA Row1	Text
3 Withholding Tax Row1	Text
3 State Tax	Text
3 Other	Text
3 Other 2	Text
3 Total Deductions	Text
3 Weekly Net Wages	Text
1 Total Fringe	Text
1. Employee Name and Address_Row_4	Text
Job Title journeyman, foreman e.g., apprentice,_Row_4	Text
e.g., carpenter, mason, plumber Work Classification/ Occupational Category_Row_4	Text
Sex M=Male F=Female N=Non-Binary_Row_4	Text
Race - see Key below	Text
Ethnicity H=Hispanic N=Non- Hispanic_Row_4	Text
4 SuS Hrs	Text
4 MS Hrs	Text
4 TuS Hrs	Text
4 WS Hrs	Text
4 ThS Hrs	Text
4 F-S Hrs	Text
4 Sa-S Hrs	Text
4 Total Hrs S	Text
4 Hourly Rate	Text
4 Su-O Hrs	Text
4 M-O Hrs	Text
4 Tu-O Hrs	Text
4 W-O Hrs	Text
4 TH-O Hrs	Text
4 F-O Hrs	Text
4 Sa-O Hrs	Text
4 Total Hrs -O	Text
4 Hourly Rate-O	Text
4 Gross Project Row1	Text
4 Gross Week	Text
4FICA Row1	Text
4 Withholding Tax Row1	Text
4 State Tax	Text
4 Other	Text
4 Other 2	Text
4 Total Deductions	Text
4 Weekly Net Wages	Text
1 Total Fringe	Text
1. Employee Name and Address_Row_5	Text
Job Title journeyman, foreman e.g., apprentice,_Row_5	Text
e.g., carpenter, mason, plumber Work Classification/ Occupational Category_Row_5	Text
Sex M=Male F=Female N=Non-Binary_Row_5	Text
Race - see Key below	Text
Ethnicity H=Hispanic N=Non- Hispanic_Row_5	Text
5 SuS Hrs	Text
5 MS Hrs	Text
5 TuS Hrs	Text
5 WS Hrs	Text
5 ThS Hrs	Text
5 F-S Hrs	Text
5 Sa-S Hrs	Text
5 Total Hrs S	Text
5 Hourly Rate	Text
5 Su-O Hrs	Text
5 M-O Hrs	Text
5 Tu-O Hrs	Text
5 W-O Hrs	Text
5 TH-O Hrs	Text
5 F-O Hrs	Text
5 Sa-O Hrs	Text
5 Total Hrs -O	Text
1 Hourly Rate-O	Text
5 Gross Project Row1	Text
5 Gross Week	Text
5 FICA Row1	Text
5 Withholding Tax Row1	Text
5 State Tax	Text
5 Other	Text
5 Other 2	Text
5 Total Deductions	Text
5 Weekly Net Wages	Text
5 Total Fringe	Text
1. Employee Name and Address_Row_6	Text
Job Title journeyman, foreman e.g., apprentice,_Row_6	Text
e.g., carpenter, mason, plumber Work Classification/ Occupational Category_Row_6	Text
Sex M=Male F=Female N=Non-Binary_Row_6	Text
Race - see Key below	Text
Ethnicity H=Hispanic N=Non- Hispanic_Row_6	Text
6 SuS Hrs	Text
6 MS Hrs	Text
6 TuS Hrs	Text
6 WS Hrs	Text
6 ThS Hrs	Text
6 F-S Hrs	Text
6 Sa-S Hrs	Text
6 Total Hrs S	Text
6 Hourly Rate	Text
6 Su-O Hrs	Text
6 M-O Hrs	Text
6 Tu-O Hrs	Text
6 W-O Hrs	Text
6 TH-O Hrs	Text
6 F-O Hrs	Text
6 Sa-O Hrs	Text
6 Total Hrs -O	Text
6 Hourly Rate-O	Text
6 Gross Project Row1	Text
6 Gross Week	Text
6 FICA Row1	Text
6 Withholding Tax Row1	Text
6 State Tax	Text
6 Other	Text
6 Other 2	Text
6 Total Deductions	Text
6 Weekly Net Wages	Text
1 Total Fringe	Text
1. Employee Name and Address_Row_7	Text
Job Title journeyman, foreman e.g., apprentice,_Row_7	Text
e.g., carpenter, mason, plumber Work Classification/ Occupational Category_Row_7	Text
Sex M=Male F=Female N=Non-Binary_Row_7	Text
Race - see Key below	Text
Ethnicity H=Hispanic N=Non- Hispanic_Row_7	Text
7 SuS Hrs	Text
7 MS Hrs	Text
7 TuS Hrs	Text
7 WS Hrs	Text
7 ThS Hrs	Text
7 F-S Hrs	Text
7 Sa-S Hrs	Text
7 Total Hrs S	Text
7 Hourly Rate	Text
7 Su-O Hrs	Text
7 M-O Hrs	Text
7 Tu-O Hrs	Text
7 W-O Hrs	Text
7 TH-O Hrs	Text
7 F-O Hrs	Text
7 Sa-O Hrs	Text
7 Total Hrs -O	Text
1 Hourly Rate-O	Text
7 Gross Project Row1	Text
7 Gross Week	Text
7 FICA Row1	Text
7 Withholding Tax Row1	Text
7 State Tax	Text
7 Other	Text
7 Other 2	Text
7 Total Deductions	Text
7 Weekly Net Wages	Text
7 Total Fringe	Text
1. Employee Name and Address_Row_8	Text
Job Title journeyman, foreman e.g., apprentice,_Row_8	Text
e.g., carpenter, mason, plumber Work Classification/ Occupational Category_Row_8	Text
Sex M=Male F=Female N=Non-Binary_Row_8	Text
Race - see Key below	Text
Ethnicity H=Hispanic N=Non- Hispanic_Row_8	Text
8 SuS Hrs	Text
8 MS Hrs	Text
8 TuS Hrs	Text
8 WS Hrs	Text
8 ThS Hrs	Text
8 F-S Hrs	Text
8 Sa-S Hrs	Text
8 Total Hrs S	Text
8 Hourly Rate	Text
8 Su-O Hrs	Text
8 M-O Hrs	Text
8 Tu-O Hrs	Text
8 W-O Hrs	Text
8 TH-O Hrs	Text
8 F-O Hrs	Text
8 Sa-O Hrs	Text
8 Total Hrs -O	Text
8 Hourly Rate-O	Text
8 Gross Project Row1	Text
8 Gross Week	Text
8 FICA Row1	Text
8 Withholding Tax Row1	Text
8 State Tax	Text
8 Other	Text
8 Other 2	Text
8 Total Deductions	Text
8 Weekly Net Wages	Text
8 Total Fringe	Text
1. Employee Name and Address_Row_9	Text
Job Title journeyman, foreman e.g., apprentice,_Row_9	Text
e.g., carpenter, mason, plumber Work Classification/ Occupational Category_Row_9	Text
Sex M=Male F=Female N=Non-Binary_Row_9	Text
Race - see Key below	Text
Ethnicity H=Hispanic N=Non- Hispanic_Row_9	Text
9 SuS Hrs	Text
9 MS Hrs	Text
9 TuS Hrs	Text
9 WS Hrs	Text
SuS Hrs Row99 ThS Hrs	Text
9 F-S Hrs	Text
9 Sa-S Hrs	Text
9 Total Hrs S	Text
9 Hourly Rate	Text
9 Su-O Hrs	Text
9 M-O Hrs	Text
9 Tu-O Hrs	Text
9 W-O Hrs	Text
9 TH-O Hrs	Text
9 F-O Hrs	Text
9Sa-O Hrs	Text
9 Total Hrs -O	Text
9 Hourly Rate-O	Text
9 Gross Project Row1	Text
9 FICA Row1	Text
9 Gross Week	Text
9 Withholding Tax Row1	Text
9 State Tax	Text
9 Other	Text
9 Other 2	Text
9 Total Deductions	Text
9Weekly Net Wages	Text
1 Total Fringe	Text
1. Employee Name and Address_Row_10	Text
Job Title journeyman, foreman e.g., apprentice,_Row_10	Text
e.g., carpenter, mason, plumber Work Classification/ Occupational Category_Row_10	Text
Sex M=Male F=Female N=Non-Binary_Row_10	Text
Race - see Key below	Text
Ethnicity H=Hispanic N=Non- Hispanic_Row_10	Text
10 SuS Hrs	Text
10 MS Hrs	Text
10 TuS Hrs	Text
10 WS Hrs	Text
10 ThS Hrs	Text
10 F-S Hrs	Text
10 Sa-S Hrs	Text
10 Total Hrs S	Text
10 Hourly Rate	Text
10 Total Hrs -O	Text
10 Hourly Rate-O	Text
10 Su-O Hrs	Text
10 M-O Hrs	Text
10 Tu-O Hrs	Text
10 W-O Hrs	Text
10 TH-O Hrs	Text
10 F-O Hrs	Text
10 Sa-O Hrs	Text
10 Gross Project Row1	Text
10 Gross Week	Text
10 FICA Row1	Text
10 Withholding Tax Row1	Text
10 State Tax	Text
10 Other	Text
10 Other 2	Text
10 Total Deductions	Text
10 Weekly Net Wages	Text
10 Total Fringe	Text
Check if additional sheets attached	Checkbox	Check this box when you are attaching one or more additional pages or sheets to this payroll certification form.
Form entry identifier	Text	Enter the identifying number shown in this small box to label the corresponding row or entry on the form (for example, '1'). Fill only if 'Fringe Benefits Paid to Approved Plans (4a)' is 'Yes'. Max length: 10 characters Depends on: Fringe Benefits Paid to Approved Plans (4a)
Project and Contractor Information
Contractor	Checkbox	Check this box when the entity completing and submitting the form is the prime contractor for the project.
Contractor or Subcontractor Name	Text	Enter the full legal name of the contractor or subcontractor responsible for this payroll certification. Fill only if 'Contractor', 'Subcontractor' is 'Yes' any. Max length: 30 characters Depends on: Contractor, Subcontractor
F.E.I.N.	Text	Enter the employer's Federal Employer Identification Number (FEIN) as assigned by the IRS. Max length: 10 characters
Business Address	Text	Enter the contractor's primary business mailing address including street, city, state, and ZIP code. Max length: 60 characters
Project Location	Text	Provide the physical address or location details where the public works project is being performed. Max length: 60 characters
Project Name	Text	Enter the official name of the project as used in the contract or project documents. Max length: 45 characters
Contract I.D. or Project I.D.	Text	Enter the contract or project identification number assigned by the awarding agency or your organization. Max length: 45 characters
Contractor Registration #	Text	Enter the contractor registration number issued by the state or other regulatory authority, if applicable. Max length: 30 characters
Payroll No.	Text	Enter the payroll number or internal payroll identifier associated with this pay period.
Date Wages Due & Paid	Date	Enter the date on which the wages for this payroll were due and paid. Max length: 10 characters
Week Ending Date	Date	Enter the week ending date for the payroll period covered by this certification. Fill only if 'Final Certification' is 'No'. Max length: 10 characters Depends on: Final Certification
Subcontractor	Checkbox	Check this box when the entity completing and submitting the form is a subcontractor on the project.
Final Certification	Checkbox	Check this box when this submission is the final payroll certification for the project (i.e., the last payroll report).
Signer Info (Name, Title, Date)
Signer Name	Text	Enter the full legal name of the person signing this form who is certifying the payroll information.
Signer Title	Text	Enter the job title or official position of the person signing the form (for example, Project Manager, Payroll Officer, or Owner).
Signature Date	Date	Provide the date the signer completed and electronically signed this certification.

NJ Department of Labor & Workforce Development Form MW-562, Payroll Certification for Public Works Projects (Contractor and Subcontractor’s Weekly and Final Certification) Instructions