This form contains 324 fields organized into 29 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Contractor / Payroll Header
Name of Contractor Checkbox
Check this box when the name entered in the adjacent field is the prime contractor responsible for the payroll.
Name of Subcontractor Checkbox
Check this box when the name entered in the adjacent field is a subcontractor (not the prime contractor) responsible for the payroll.
Contractor Name Text
Enter the full name of the contractor or subcontractor responsible for this payroll.
Contractor Address Text
Enter the contractor's address for this payroll record (street address, city, state, and ZIP as appropriate).
Payroll Number Text
Enter the payroll number or identifier assigned to this payroll report.
Week Ending Date Date
Enter the week-ending date for the payroll period covered by this form.
Project and Location Text
Enter the name and physical location of the project associated with this payroll.
Project or Contract Number Text
Enter the project or contract number assigned to this job or contract.
Day/Date Column 1 Date
Enter the day and date for the first day of the workweek shown in this column.
Max length: 2 characters
Day/Date Column 2 Date
Enter the day and date for the second day of the workweek shown in this column.
Max length: 2 characters
Day/Date Column 3 Date
Enter the day and date for the third day of the workweek shown in this column.
Max length: 2 characters
Day/Date Column 4 Date
Enter the day and date for the fourth day of the workweek shown in this column.
Max length: 2 characters
Day/Date Column 5 Date
Enter the day and date for the fifth day of the workweek shown in this column.
Max length: 2 characters
Day/Date Column 6 Date
Enter the day and date for the sixth day of the workweek shown in this column.
Max length: 2 characters
Day/Date Column 7 / Total Hours Header Date
Enter the day and date for the seventh day of the workweek shown in this column or use this column header for total hours as applicable.
Max length: 2 characters
Withholding Tax Deduction Number
Enter the amount withheld for income tax from the employee's pay for the week.
Other Deductions Number
Enter any other deduction amounts (non-FICA, non-withholding) taken from the employee's pay for the week.
Hours Worked — Day 1 Number
Enter the number of hours worked by the employee on the first day of the payroll week.
Max length: 16 characters
Hours Worked — Day 2 Number
Enter the number of hours worked by the employee on the second day of the payroll week.
Max length: 16 characters
Hours Worked — Day 3 Number
Enter the number of hours worked by the employee on the third day of the payroll week.
Max length: 16 characters
Hours Worked — Day 4 Number
Enter the number of hours worked by the employee on the fourth day of the payroll week.
Max length: 16 characters
Hours Worked — Day 5 Number
Enter the number of hours worked by the employee on the fifth day of the payroll week.
Max length: 16 characters
Total Hours for Week Number
Enter the total number of hours worked by the employee for the entire payroll week.
Max length: 16 characters
Contractor / Payroll Period / Project Info
Contractor / Employer Name Text
Enter the full legal name of the contractor or subcontractor that employs the persons covered by this payroll.
Building or Work (Project) Text
Enter the name or brief description of the building, work, or project (and location) where the labor was performed.
Payroll Period Start — Day Text
Enter the day of the month on which the payroll period begins.
Payroll Period Start — Month Text
Enter the month when the payroll period begins (name or abbreviation).
Payroll Period Start — Year Text
Enter the year when the payroll period begins.
Max length: 4 characters
Payroll Period End — Day Text
Enter the day of the month on which the payroll period ends.
Payroll Period End — Month Text
Enter the month when the payroll period ends (name or abbreviation).
Payroll Period End — Year Text
Enter the year when the payroll period ends.
Max length: 4 characters
Contractor/Subcontractor (Referenced Entity) Text
Enter the full legal name of the contractor or subcontractor referenced in this statement (the entity on whose behalf rebates would be made, if any).
Deductions
Permissible deductions as defined in Regulation, Part 3 29 CFR Subtitle A Text
Enter permissible deductions as defined in Regulation, Part 3 29 CFR Subtitle A.
Permissible deductions as defined in Regulation, Part 3 29 CFR Subtitle A Text
Enter permissible deductions as defined in Regulation, Part 3 29 CFR Subtitle A.
Permissible deductions as defined in Regulation, Part 3 29 CFR Subtitle A Text
Enter permissible deductions as defined in Regulation, Part 3 29 CFR Subtitle A.
Permissible deductions as defined in Regulation, Part 3 29 CFR Subtitle A Text
Enter permissible deductions as defined in Regulation, Part 3 29 CFR Subtitle A.
Where fringe benefits are paid to approved plans, funds, or programs (in addition to basic hourly wages) Checkbox
Check this box if fringe benefits for the listed laborers or mechanics were paid to approved plans, funds, or programs in addition to the basic hourly wage rates as indicated on the payroll.
Eighth Employee Row (row 8)
Daily hours (row 8) Number
Enter the hours worked by this employee for each day of the workweek in the daily hours column for row 8.
Max length: 16 characters
Employee name / identifying number (row 8) Text
Enter the employee's full name and identifying number for row 8 (for example, the last four digits of the employee's Social Security number).
Withholding exemptions (row 8) Text
Enter the number of withholding exemptions claimed by this employee for payroll purposes on row 8.
Max length: 2 characters
Work classification / job code (row 8) Text
Enter the employee's work classification or job code used to classify the type of work performed for row 8.
Total hours (row 8) Number
Enter the total hours worked by the employee for the entire workweek shown on row 8.
Rate of pay (row 8) Number
Enter the employee's rate of pay for the period shown on row 8.
Gross T8 Text
Enter the total gross wages earned by the employee for this payroll period.
FICA withheld (row 8) Number
Enter the FICA (Social Security and Medicare) amount withheld from this employee's pay for the week on row 8.
Withholding tax (row 8) Number
Enter the federal/state income tax withholding amount deducted from this employee's pay for the week on row 8.
Other deduction 1 (row 8) Number
Enter the first other deduction amount (for example union dues or benefit contributions) deducted from this employee's pay for the week on row 8.
Other deduction 2 (row 8) Number
Enter the second other deduction amount deducted from this employee's pay for the week on row 8.
Other deduction 3 (row 8) Number
Enter the third other deduction amount deducted from this employee's pay for the week on row 8.
Total deductions (row 8) Number
Enter the total of all deductions withheld from this employee's pay for the week on row 8.
Net wages paid (row 8) Number
Enter the net wages paid to the employee for the week after all deductions on row 8.
Exception Row 1 (Craft / Explanation)
Exception (Craft) Text
Enter the craft, trade, or job classification for the exception row (for example 'Carpenter' or 'Laborer') that identifies which workers the exception applies to.
Explanation Text
Enter a brief explanation describing the reason or details of the exception for the craft listed in this row (e.g., scope, hours, wage adjustment, or justification).
Exception Row 2 (Craft / Explanation)
Exception (Craft) Text
Enter the trade, craft, or job classification for which you are claiming an exception (for example 'Carpenter', 'Laborer', or 'Electrician').
Explanation of Exception Text
Provide a brief, clear explanation describing why the listed craft qualifies for the exception, including any relevant details or justification specific to this payroll period.
Exception Row 3 (Craft / Explanation)
Exception (Craft) — Row 3 Text
Enter the trade or craft classification (for example: Carpenter, Electrician, Laborer) that describes the worker group covered by this exception on row 3.
Explanation — Row 3 Text
Provide a brief description explaining the reason for the exception listed in the craft column on row 3, such as the specific fringe benefit arrangement or circumstance that justifies the exception.
Exception Row 4 (Craft / Explanation)
Exception (Craft) — Row 4 Text
Enter the trade, craft, or job classification for the fourth exception row (e.g., 'Carpenter', 'Laborer') as it applies to this payroll entry.
Explanation — Row 4 Text
Provide a brief explanation or reason for the exception listed on row 4, describing why the classification or wage differs from the standard (e.g., special duties, apprenticeship status, or other allowance).
Exception Row 5 (Craft / Explanation)
Exception (Craft) - Row 5 Text
Enter the trade or craft classification for the exception being reported in row 5 (for example, 'Carpenter', 'Laborer', or other job classification).
Explanation - Row 5 Text
Provide a brief explanation describing the reason or circumstances for the exception listed in row 5 (what makes this worker or pay entry an exception).
Exception Row 6 (Craft / Explanation)
Exception (Craft) Text
Enter the trade, job classification, or craft for which an exception is being claimed (for example: Painter, Carpenter, Laborer).
Explanation Text
Provide a brief description explaining the reason for the exception, including facts or circumstances that justify the claimed exception for the craft listed to the left.
Exception Row 7 (Craft / Explanation)
Exception (Craft) Text
Enter the craft, trade, or job classification to which this exception applies (for example, 'Carpenter', 'Laborer', or other specific craft).
Explanation Text
Provide a brief explanation describing the reason or details for the exception listed for the corresponding craft.
Exception Row 8 (Craft / Explanation)
Exception (Craft) Text
Enter the trade or craft classification (e.g., Carpenter, Laborer, Electrician) for the exception being reported on this row.
Explanation Text
Provide a concise explanation describing the reason for the exception for the craft listed on this row (include circumstances, dates, or other relevant details).
Fifth Employee Row (row 5)
Employee name and ID Text
Enter the employee's full name and identifying number (for example, the last four digits of the Social Security number).
Withholding exemptions Text
Enter the number of withholding exemptions claimed by this employee for the payroll period.
Max length: 2 characters
Work classification Text
Enter the employee's job classification or trade used for this contract (for example, Carpenter, Laborer, etc.).
Total hours worked Number
Enter the total hours the employee worked during this payroll week.
Rate of pay Number
Enter the employee's hourly rate of pay applicable for this payroll period.
Gross amount earned Number
Enter the total gross wages earned by the employee for the week before any deductions.
FICA deduction Number
Enter the amount withheld from the employee's wages for FICA taxes for the week.
Withholding tax deduction Number
Enter the amount of federal income tax withheld from the employee's wages for the week.
Other deduction (1) Number
Enter the amount of any other deduction (for example union dues, insurance) withheld from the employee's wages for the week.
Other deduction (2) Number
Enter the amount of any additional deduction not captured in the prior deduction column for this employee for the week.
Total deductions Number
Enter the sum of all deduction amounts withheld from the employee's gross wages for the week.
Net wages paid Number
Enter the net wages actually paid to the employee for the week after all deductions.
Net wages paid (additional field) Number
Use this field for any additional net-pay amount or portion if the form separates the net wages into more than one entry.
Rate of pay ST fringe 6 Text
Enter the fringe benefit rate of pay for the employee for this pay period.
Rate of pay ST 7 Text
Enter the rate of pay for the standard time hours worked by the employee.
Rate of pay ST fringe 7 Text
Enter the rate of pay for the standard time fringe benefits for the employee.
First Employee Row (row 1)
Employee name and ID Text
Enter the employee's full name and an individual identifying number (for example, the last four digits of the employee's Social Security number).
Withholding exemptions Text
Enter the number of withholding exemptions the employee claims for this payroll period.
Max length: 2 characters
Work classification Text
Enter the employee's work classification or job code used on this contract (for example, 'Carpenter', 'Laborer', or the classification code).
Hours worked each day Number
Enter the hours worked by the employee for each day of the payroll week in the vertical daily boxes.
Max length: 16 characters
Rate of pay Number
Enter the employee's rate of pay applicable to the hours reported.
Additional rate / overtime rate Number
Enter any additional or overtime rate of pay applicable to this employee (if used).
Hours at additional rate Number
Enter the number of hours worked at the additional or overtime rate reported in the adjacent rate field.
Gross amount earned (primary) Number
Enter the gross earnings for this employee attributable to the primary rate and hours shown.
Gross amount earned (additional) Number
Enter any additional gross earnings for the employee that are not included in the primary gross amount field.
FICA deduction Number
Enter the amount withheld from the employee's pay for FICA (Social Security/Medicare) contributions.
Withholding tax (federal) Number
Enter the amount of federal income tax withheld from the employee's pay for the week.
Withholding tax (state/local) Number
Enter any state or local income tax withheld from the employee's pay for the week.
Other deductions Number
Enter the total of any other deductions taken from the employee's pay (for example union dues, insurance, or retirement contributions).
Total deductions Number
Enter the sum of all deduction columns for this employee for the payroll week.
Additional deduction/adjustment Number
Enter any additional deduction or payroll adjustment amount for this employee not captured in the other deduction columns.
Net wages paid for week Number
Enter the net amount actually paid to the employee for the payroll week after all deductions.
Fourth Employee Row (row 4)
Employee name / ID Text
Enter the employee's name and identifying number (for example, name and last four digits of SSN) as shown on payroll records.
Number of withholding exemptions Text
Enter the number of federal withholding exemptions the employee claims for this payroll period.
Max length: 2 characters
Work classification Text
Enter the worker's job classification or trade (for example, carpenter, electrician) used for this project.
Total hours worked Number
Enter the total hours the employee worked during the payroll week.
Rate of pay Number
Enter the employee's rate of pay.
Gross amount earned Number
Enter the employee's total gross wages earned for the week before any deductions.
FICA deduction Number
Enter the amount deducted from the employee's pay for FICA this week.
Withholding tax deduction Number
Enter the amount withheld for federal income tax from the employee's pay this week.
Other deduction 1 Number
Enter the amount of any other deduction (for example union dues or benefit contributions) taken from this employee's pay this week.
Other deduction 2 Number
Enter any additional other deduction amount for this employee for the week.
Total deductions Number
Enter the total of all deductions taken from this employee's pay for the week.
Net wages (dollars) Number
Enter the net wages paid to the employee for the week after all deductions.
Net wages (cents/continuation) Number
Enter the remaining portion of the net wages paid to the employee for the week as shown on the form.
rateOfPayST5 Text
Enter the rate of pay for straight time hours for the fifth employee.
Rate of pay ST fringe 5 Text
Enter the rate of pay for straight time fringe benefits for the fifth employee.
Rate of pay ST 6 Text
Enter the rate of pay for the employee for this pay period.
Fringe Benefits
Fringe benefits paid in cash 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 benefits as indicated on the payroll.
Name and Title (Signature Area)
Name and Title of Signatory Text
Enter the full printed name and job title of the person signing this form (the signatory responsible for the payroll certification).
Overtime Hours
OT21 Text
Enter the overtime hours worked by the second worker on day 1.
OT22 Text
Enter the overtime hours worked by the second worker on day 2.
OT23 Text
Enter the overtime hours worked by the second worker on day 3.
OT24 Text
Enter the overtime hours worked by the second worker on day 4.
OT25 Text
Enter the overtime hours worked by the second worker on day 5.
OT26 Text
Enter the overtime hours worked by the second worker on day 6.
OT27 Text
Enter the overtime hours worked by the second worker on day 7.
Total hours OT2 Text
Enter the total overtime hours worked by the second worker.
OT51 Text
Enter the overtime hours worked by the fifth employee on the first day.
OT52 Text
Enter the overtime hours worked by the fifth employee on the second day.
OT53 Text
Enter the overtime hours worked by the fifth employee on the third day.
OT54 Text
Enter the overtime hours worked by the fifth employee on the fourth day.
OT55 Text
Enter the overtime hours worked by the fifth employee on the fifth day.
OT56 Text
Enter the overtime hours worked by the fifth employee on the sixth day.
OT57 Text
Enter the overtime hours worked by the fifth employee on the seventh day.
Total hours OT5 Text
Enter the total overtime hours worked by the fifth employee.
OT61 Text
Enter the overtime hours for the sixth employee on day 1.
OT62 Text
Enter the overtime hours for the sixth employee on day 2.
OT63 Text
Enter the overtime hours for the sixth employee on day 3.
OT64 Text
Enter the overtime hours for the sixth employee on day 4.
OT65 Text
Enter the overtime hours for the sixth employee on day 5.
OT66 Text
Enter the overtime hours for the sixth employee on day 6.
OT67 Text
Enter the overtime hours for the sixth employee on day 7.
Total hours OT6 Text
Enter the total overtime hours for the sixth employee.
Payroll Details
day1 Text
Enter the hours worked on Day 1.
Day 2 Text
Enter the hours worked on Day 2.
Day 3 Text
Enter the hours worked on Day 3.
Day 4 Text
Enter the hours worked on Day 4.
Day 5 Text
Enter the hours worked on Day 5.
Day 6 Text
Enter the hours worked on Day 6.
Day 7 Text
Enter the hours worked on Day 7.
date1 Text
Enter the date for Day 1 in mm/dd/yyyy format.
Date 2 Text
Enter the date for Day 2 in mm/dd/yyyy format.
Date 3 Text
Enter the date for Day 3 in mm/dd/yyyy format.
Date 4 Text
Enter the date for Day 4 in mm/dd/yyyy format.
Date 5 Text
Enter the date for Day 5 in mm/dd/yyyy format.
Date 6 Text
Enter the date for Day 6 in mm/dd/yyyy format.
Date 7 Text
Enter the date for Day 7 in mm/dd/yyyy format.
OT11 Text
Enter the number of overtime hours worked by the employee on day 1.
OT12 Text
Enter the number of overtime hours worked by the employee on day 2.
OT13 Text
Enter the number of overtime hours worked by the employee on day 3.
OT14 Text
Enter the number of overtime hours worked by the employee on day 4.
OT15 Text
Enter the number of overtime hours worked by the employee on day 5.
OT16 Text
Enter the number of overtime hours worked by the employee on day 6.
OT17 Text
Enter the number of overtime hours worked by the employee on day 7.
Total hours OT1 Text
Enter the total number of overtime hours worked by the employee for the week.
ST11 Text
Enter the number of straight time hours worked by the employee on day 1.
ST12 Text
Enter the number of straight time hours worked by the employee on day 2.
ST13 Text
Enter the number of straight time hours worked by the employee on day 3.
ST14 Text
Enter the number of straight time hours worked by the employee on day 4.
ST15 Text
Enter the number of straight time hours worked by the employee on day 5.
ST16 Text
Enter the number of straight time hours worked by the employee on day 6.
ST17 Text
Enter the number of straight time hours worked by the employee on day 7.
Total hours ST1 Text
Enter the total number of straight time hours worked by the employee for the week.
Total hours ST2 Text
Enter the total number of standard time (ST) hours worked by the employee in the second period.
OT31 Text
Enter the overtime (OT) hours worked by the employee in the third period.
OT32 Text
Enter the overtime (OT) hours worked by the employee in the third period.
OT33 Text
Enter the overtime (OT) hours worked by the employee in the third period.
OT34 Text
Enter the overtime (OT) hours worked by the employee in the third period.
OT35 Text
Enter the overtime (OT) hours worked by the employee in the third period.
OT36 Text
Enter the overtime (OT) hours worked by the employee in the third period.
OT37 Text
Enter the overtime (OT) hours worked by the employee in the third period.
Total hours OT3 Text
Enter the total number of overtime (OT) hours worked by the employee in the third period.
ST31 Text
Enter the standard time hours worked by the third worker on the first day.
ST32 Text
Enter the standard time hours worked by the third worker on the second day.
ST33 Text
Enter the standard time hours worked by the third worker on the third day.
ST34 Text
Enter the standard time hours worked by the third worker on the fourth day.
ST35 Text
Enter the standard time hours worked by the third worker on the fifth day.
ST36 Text
Enter the standard time hours worked by the third worker on the sixth day.
ST37 Text
Enter the standard time hours worked by the third worker on the seventh day.
Total hours ST3 Text
Enter the total standard time hours worked by the third worker.
OT41 Text
Enter the overtime hours worked by the fourth worker on the first day.
OT42 Text
Enter the overtime hours worked by the employee for the specified period.
OT43 Text
Enter the overtime hours worked by the employee for the specified period.
OT44 Text
Enter the overtime hours worked by the employee for the specified period.
OT45 Text
Enter the overtime hours worked by the employee for the specified period.
OT46 Text
Enter the overtime hours worked by the employee for the specified period.
OT47 Text
Enter the overtime hours worked by the employee for the specified period.
Total hours OT4 Text
Enter the total overtime hours worked by the employee for the specified period.
ST41 Text
Enter the standard hours worked by the employee for the specified period.
ST42 Text
Enter the standard hours worked by the employee for the specified period.
ST43 Text
Enter the standard hours worked by the employee for the specified period.
ST44 Text
Enter the standard hours worked by the employee for the specified period.
ST45 Text
Enter the standard hours worked by the employee for the specified period.
ST46 Text
Enter the standard hours worked by the employee for the specified period.
ST47 Text
Enter the standard hours worked by the employee for the specified period.
Total hours ST4 Text
Enter the total standard hours worked by the employee for the specified period.
Total hours ST6 Text
Enter the total hours worked by the employee for this pay period.
OT71 Text
Enter the overtime hours worked by the employee for this pay period.
OT72 Text
Enter the overtime hours worked by the employee for this pay period.
OT73 Text
Enter the overtime hours worked by the employee for this pay period.
OT74 Text
Enter the overtime hours worked by the employee for this pay period.
OT75 Text
Enter the overtime hours worked by the employee for this pay period.
OT76 Text
Enter the overtime hours worked by the employee for the specified period.
OT77 Text
Enter the overtime hours worked by the employee for the specified period.
Total hours OT7 Text
Enter the total overtime hours worked by the employee for the specified period.
ST71 Text
Enter the standard time hours worked by the employee for the specified period.
ST72 Text
Enter the standard time hours worked by the employee for the specified period.
ST73 Text
Enter the standard time hours worked by the employee for the specified period.
ST74 Text
Enter the standard time hours worked by the employee for the specified period.
ST75 Text
Enter the standard time hours worked by the employee for the specified period.
ST76 Text
Enter the standard time hours worked by the employee for the specified period.
ST77 Text
Enter the standard time hours worked by the employee for the specified period.
Total hours ST7 Text
Enter the total standard time hours worked by the employee for the specified period.
OT81 Text
Enter the overtime hours worked by the employee on the first day of the payroll period.
OT82 Text
Enter the overtime hours worked by the employee on the second day of the payroll period.
OT83 Text
Enter the overtime hours worked by the employee on the third day of the payroll period.
OT84 Text
Enter the overtime hours worked by the employee on the fourth day of the payroll period.
OT85 Text
Enter the overtime hours worked by the employee on the fifth day of the payroll period.
OT86 Text
Enter the overtime hours worked by the employee on the sixth day of the payroll period.
OT87 Text
Enter the overtime hours worked by the employee on the seventh day of the payroll period.
Total hours OT8 Text
Enter the total overtime hours worked by the employee during the payroll period.
ST81 Text
Enter the straight time hours worked by the employee on the first day of the payroll period.
ST82 Text
Enter the straight time hours worked by the employee on the second day of the payroll period.
ST83 Text
Enter the straight time hours worked by the employee on the third day of the payroll period.
ST84 Text
Enter the straight time hours worked by the employee on the fourth day of the payroll period.
ST85 Text
Enter the straight time hours worked by the employee on the fifth day of the payroll period.
ST86 Text
Enter the straight time hours worked by the employee on the sixth day of the payroll period.
ST87 Text
Enter the straight time hours worked by the employee on the seventh day of the payroll period.
Total hours ST8 Text
Enter the total straight time hours worked by the employee during the payroll period.
Project Information
ST64 Text
Enter the state abbreviation for the project location.
ST65 Text
Enter the state abbreviation for the project location.
ST66 Text
Enter the state abbreviation for the project location.
ST67 Text
Enter the state abbreviation for the project location.
Remarks
Remarks / Additional Information Text
Enter any additional comments, explanations, exceptions, or other relevant information about the payroll, fringe benefits, apprenticeships, or certification statements required by this form.
Second Employee Row (row 2)
Employee name Text
Enter the full name of the employee whose pay is reported on this row.
Employee identifying number Text
Enter the worker's individual identifying number (for example, the last four digits of the employee's Social Security number).
Max length: 2 characters
Work classification Text
Enter the employee's job classification, trade or work code that applies to the hours shown.
Total hours worked Number
Enter the total number of hours the employee worked during the payroll week.
Rate of pay (part 1) Number
Enter the employee's rate of pay applicable to the hours reported in this row.
Rate of pay (part 2) Number
Enter any additional or alternate rate of pay for this employee (leave blank if not used).
Gross amount earned (part 1) Number
Enter the gross wages earned by the employee for the hours shown before any deductions.
Gross amount earned (part 2) Number
Enter any additional gross pay for this employee for the pay period (e.g., separate pay component or continuation of the gross amount).
FICA withheld Number
Enter the amount withheld from this employee's pay for FICA taxes for the week.
Withholding tax withheld (federal/state) Number
Enter the amount withheld from the employee's pay for income tax (federal and/or state as applicable) for the week.
Other deductions (part 1) Number
Enter any other payroll deductions taken from the employee's pay (such as union dues, loan payments, or benefit contributions).
Other deductions (part 2) Number
Enter any additional other deduction amounts for this employee for the pay period (leave blank if not used).
Total deductions Number
Enter the sum of all deductions withheld from the employee's gross wages for the week.
Net wages paid (part 1) Number
Enter the net wages paid to the employee for the week after all deductions are subtracted from gross pay.
Net wages paid (part 2) Number
Enter any additional net wage amount or continuation of the net wages figure for this employee if the form splits the amount across multiple boxes.
Rate of pay ST 3 Text
Enter the standard rate of pay for the third worker.
Seventh Employee Row (row 7)
Employee name and ID Text
Enter the employee's name and individual identifying number (typically the last four digits of the Social Security number).
Withholding exemptions Text
Enter the number of federal withholding exemptions claimed by this employee for the pay period.
Max length: 2 characters
Work classification Text
Enter the worker's job classification code or brief job title used for this contract or payroll record.
Total hours worked Number
Enter the total hours the employee worked during the pay period.
Rate of pay Number
Enter the employee's pay rate for this pay period (hourly or other applicable rate).
Gross amount earned Number
Enter the total gross wages earned by the employee for the pay period before deductions.
FICA deduction Number
Enter the amount withheld from the employee's pay for FICA (Social Security/Medicare) for this pay period.
Withholding tax deduction Number
Enter the amount withheld from the employee's pay for federal (and applicable state) income tax for this pay period.
Other deduction 1 Number
Enter the amount of any other deduction (for example union dues or benefit contributions) withheld from this employee's pay for the pay period.
Other deduction 2 Number
Enter the amount of an additional other deduction withheld from this employee's pay for the pay period.
Other deduction 3 Number
Enter the amount of any further other deduction withheld from this employee's pay for the pay period.
Total deductions Number
Enter the sum of all deductions withheld from the employee's pay for the pay period.
Net wages paid Number
Enter the net wages actually paid to the employee for the week after all deductions.
Signatory Info
Date Date
Enter the date when the signatory is completing and signing this form.
Name of Signatory Text
Enter the full name of the person (signatory party) who is attesting to and signing the form.
Signatory Title Text
Enter the official job title or position of the signatory (for example, Owner, Manager, or Project Superintendent).
Sixth Employee Row (row 6)
Employee name and ID Text
Enter the employee's full name and identifying number (for example, last four digits of the Social Security number) as shown on payroll records.
Number of withholding exemptions Text
Enter the number of withholding exemptions claimed by the employee for payroll withholding purposes.
Max length: 2 characters
Work classification Text
Enter the worker's job classification or trade code used to categorize the type of work performed.
Total hours worked Number
Enter the total hours the employee worked during the pay week.
Rate of pay Number
Enter the employee's pay rate corresponding to the hours worked.
Gross amount earned Number
Enter the total gross wages earned by the employee for the pay week before any deductions.
FICA deduction Number
Enter the amount withheld from the employee's pay for FICA (Social Security/Medicare) for the pay period.
Withholding tax deduction Number
Enter the amount withheld from the employee's pay for federal income tax withholding for the pay period.
Other deduction 1 Number
Enter the first other deduction amount withheld from the employee's pay (e.g., union dues, loan repayment) for the pay period.
Other deduction 2 Number
Enter the second other deduction amount withheld from the employee's pay for the pay period, if applicable.
Other deduction 3 Number
Enter the third other deduction amount withheld from the employee's pay for the pay period, if applicable.
Total deductions Number
Enter the sum of all deductions withheld from the employee's pay for the pay week.
Net wages paid for week Number
Enter the employee's net pay for the week after all deductions have been applied.
Row-specific code or note (1) Text
Enter any short internal code, classification note, or brief remark associated with this employee's row as required by the contractor.
Row-specific code or note (2) Text
Enter any additional short internal code or supplemental note for payroll processing related to this employee's row.
Standard Hours
ST21 Text
Enter the standard hours worked by the second worker on day 1.
ST22 Text
Enter the standard hours worked by the second worker on day 2.
ST23 Text
Enter the standard hours worked by the second worker on day 3.
ST24 Text
Enter the standard hours worked by the second worker on day 4.
ST25 Text
Enter the standard hours worked by the second worker on day 5.
ST26 Text
Enter the standard hours worked by the second worker on day 6.
ST27 Text
Enter the standard hours worked by the second worker on day 7.
ST61 Text
Enter the standard time hours for the sixth employee on day 1.
ST62 Text
Enter the standard time hours for the sixth employee on day 2.
ST63 Text
Enter the standard time hours for the sixth employee on day 3.
Straight Time Hours
ST51 Text
Enter the straight time hours worked by the fifth employee on the first day.
ST52 Text
Enter the straight time hours worked by the fifth employee on the second day.
ST53 Text
Enter the straight time hours worked by the fifth employee on the third day.
ST54 Text
Enter the straight time hours worked by the fifth employee on the fourth day.
ST55 Text
Enter the straight time hours worked by the fifth employee on the fifth day.
ST56 Text
Enter the straight time hours worked by the fifth employee on the sixth day.
ST57 Text
Enter the straight time hours worked by the fifth employee on the seventh day.
Total hours ST5 Text
Enter the total straight time hours worked by the fifth employee.
Third Employee Row (row 3)
Employee name / ID Text
Enter the employee's full name and identifying number (for example, the last four digits of the employee's Social Security number).
Employee count/Exemptions Text
Enter the small numeric count required by the form for this worker (for example, number of exemptions or classification count).
Max length: 2 characters
Work classification Text
Enter the employee's job classification, trade, or job code used on this payroll entry.
Total hours Number
Enter the total hours worked by this employee for the week.
Overtime / alternate hours Number
Enter the hours worked at overtime or an alternate rate for this employee for the week, if any.
Rate of pay Number
Enter the employee's hourly rate of pay.
Gross amount earned Number
Enter the gross wages earned by the employee for the week before any deductions.
FICA withheld Number
Enter the amount of FICA (Social Security/Medicare) tax withheld from the employee's pay for the week.
Withholding tax Number
Enter the amount of federal or state withholding tax withheld from this employee for the week.
Other deduction 1 Number
Enter any other individual deduction (for example union dues or benefit contributions) withheld from this employee this week.
Other deduction 2 Number
Enter any additional deduction withheld from this employee for the week.
Total deductions Number
Enter the total of all deductions withheld from the employee's pay for the week.
Net wages paid (part 1) Number
Enter the net wages paid to the employee for the week (this field is one part of the net pay entry).
Net wages paid (part 2) Number
Enter the net wages paid to the employee for the week (this field is the adjacent part of the net pay entry).
Rate of pay ST 4 Text
Enter the rate of pay for the standard hours worked by the employee.
Rate of pay ST fringe 4 Text
Enter the fringe benefit rate of pay for the standard hours worked by the employee.
Wages / Deductions Description
Wages / Deductions Description Text
Enter a clear, concise description of the wages, deductions, fringe benefits or other payroll items for the payroll period, including any relevant categories, explanations or notes needed to explain amounts shown on the payroll. Fill only if 'Where fringe benefits are paid to approved plans, funds, or programs (in addition to basic hourly wages)' is 'Yes'.
Max length: 4 characters
Depends on: Where fringe benefits are paid to approved plans, funds, or programs (in addition to basic hourly wages)