3090-XXXX_Supplemental Information-Electronic Form

Section 1: Payroll General Information
Data Element Name
Prime or Subcontractor

Desired Functionality and Format
(What we'd like the application to do)
Select Prime or Subcontractor; could be a checkbox or drop down

Contractor Name and Address
Payroll No.
For Week Ending
Contract or Task Order Number (If project is a task order, list the
task order number)

Section 2: Payroll Employee Information
The below columns should duplicate with each additional employee they have. Should we include a column where they type in the
amount of employees and the form will duplicate each input? Suggestions?
Employee Name and Individual Identifying Number (e.g., Last
four digits of Social Security Number) of Worker

Full social security numbers and home addresses shall not be
included. I am wondering how we could emphasize that with their
input.

Work Classification Corresponding to the Applicable Wage
Determination (Contractors employing apprentices or trainees
under approved programs shall upload the written evidence of
the registration of apprenticeship programs and certification of
trainee programs, the registration of the apprentices and
trainees, and the ratios and wage rates prescribed in the
applicable programs in accordance with FAR 52.222-9)
Day and Date Hours Worked Each Day for Overtime
Day and Date Hours Worked Each Day for StraightTime
Total Hours Worked for Overtime
Total Hours Worked for Straight Time
Rate of Pay- Straight
Rate of Fringe Benefits- Straight Time
Rate of Pay- Overtime
Rate of Fringe Benefits- Overtime
Gross Amount Earned- Overtime
Gross Amount Earned- Straight
Deductions - FICA

Self Explanatory

Deductions- Witholding Tax

Self Explanatory

Deductions- Other

Can we have an "add" or "+" symbol? The amount of "Other
Deductions" varies from person to person and the contractor
should be able to identify the name of the deduction by typing it
in.

Deductions- Other

Can we have an "add" or "+" symbol? The amount of "Other
Deductions" varies from person to person and the contractor
should be able to identify the name of the deduction by typing it
in.

Deductions- Other

Can we have an "add" or "+" symbol? The amount of "Other
Deductions" varies from person to person and the contractor
should be able to identify the name of the deduction by typing it
in.

Net Wages Paid for the Week

Self Explanatory

Section 3: Statement of Compliance
Name of Signatory Party
Title
Date

This statement of compliance will mimic the one on the WH347 below but can be tailored

Narrative: "I do hereby state that I pay or supervise the payment
of the persons employed by"
This will show as a narrative.
Name of contractor or subcontractor

Type in name

Narrative: "on the aforementioned contract/task order number
above; that during this payroll period week covered, all persons
employed on said project have been paid the ful weekly wages
earned, that no rebates have been or will be made either directly
of indirectly to or on behalf of said, "

This will show as a narrative.

Name of contractor or subcontractor

Type in name

Narrative: "from the full weekly wages earned by any person and
that no deductions have been made either directly or indirectly
from the full wages earned by any person, other than permissible
deductions as defined in Regulations, Part
3 (29 C.F.R. Subtitle A), issued by the Secretary of Labor under
the Copeland Act, as amended (48 Stat. 948,
63 Start. 108, 72 Stat. 967; 76 Stat. 357; 40 U.S.C. § 3145), and
described below:"
This will show as a narrative.
List of Permissible Deductions (if applicable)

Contractor/subcontractor will type in permissible deductions if
applicable.

Narative: "(2) That any payrolls otherwise under this contract
required to be submitted for the above period are
correct and complete; that the wage rates for laborers or
mechanics contained therein are not less than the
applicable wage rates contained in any wage determination
incorporated into the contract; that the classifications
set forth therein for each laborer or mechanic conform with the
work he performed.
(3) That any apprentices employed in the above period are duly
registered in a bona fide apprenticeship
program registered with a State apprenticeship agency
recognized by the Bureau of Apprenticeship and
Training, United States Department of Labor, or if no such
recognized agency exists in a State, are registered
with the Bureau of Apprenticeship and Training, United States
Department of

This will show as a narrative.

Where Fringe Benefits are Paid to Approved Plans, Funds, or
Programs
-in addition to the basic hourly wage rates paid to each laborer or
mechanic listed in
the above referenced payroll, payments of fringe benefits as
listed in the contract
have been or will be made to appropriate programs for the
benefit of such employees,
except as noted in the exceptions below.
Checkbox
Where Fringe Benefits are Paid in Cash
- each laborer or mechanic listed in the above referenced payroll
has been paid,
as indicated on the payroll, an amount not less than the sum of
the applicable
basic hourly wage rate plus the amount of the required fringe
benefits as listed
in the contract, except as noted in the exceptions below.

Checkbox

Exceptions (List the Craft(s) for the Exception)

If either of the boxes are checked in the two rows above, this
becomes a mandatory field. They will be able to provide a
narrative type entry.

Exceptions (List the Explanation(s) for the Exception)

If either of the boxes are checked in the two rows above, this
becomes a mandatory field. They will be able to provide a
narrative type entry.

Name and Title

How will we allow subcontractors to certify this?

Signature

How will we allow subcontractors to certify this?

Some people may not have the ability to digitally sign. Do we have any alternatives or should we just
allow them to provide wet signatures on this page but the other page must be a digital copy?