Contractors and subcontractors on Davis-Bacon covered projects may use this format; the required submission is a weekly payroll with a signed Statement of Compliance. This pack covers Project A only. Project B (California state job) is filed separately through California's system and is not on this form. Presentation note: columns are lightly simplified for readability (the current WH-347, Rev. January 2025, splits fringe credit and cash-in-lieu into separate columns and presents the compliance statement as checkboxes with identical substance); every figure here reconciles exactly as shown.
| Contractor / Subcontractor: Summit Ridge Electrical LLC (subcontractor) | Payroll No.: 14 |
| Project & Location: Riverside Elementary School Modernization — San Tomas, CA | Week ending: Sunday, November 1, 2026 |
| Prime contractor: Callahan Builders Inc. (payrolls are submitted to the prime / contracting agency — see verification memo) | Contract / FLSA week: Mon Oct 26 – Sun Nov 1, 2026 (work performed Mon–Fri) |
| Classification | Base rate | Fringe | Total prevailing | How fringe is paid |
|---|---|---|---|---|
| Electrician | $38.50 | $12.75 | $51.25 | Cash in lieu, on the paycheck (§(c) election below) |
| Laborer | $22.15 | $6.25 | $28.40 | Cash in lieu, on the paycheck |
| Electrician Apprentice, Period 3 (registered) — 60% of journeyman base | $23.10 | $12.75 | $35.85 | Cash in lieu, on the paycheck |
| Employee | Work classification | Mon 10/26 | Tue 10/27 | Wed 10/28 | Thu 10/29 | Fri 10/30 |
Total hrs this project | Rate of pay (base + cash fringe) | Gross earned this project |
FICA (7.65%) | Federal WH | State WH | Other ded. | Total ded. | Net paid this project |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Marcus Webb | Electrician | 8 | 8 | 8 | 8 | 8 | 40 | $51.25 | $2,050.00 | $156.83 | $205.00 | $82.00 | $25.00 | $468.83 | $1,581.17 |
| Dana Ortiz | Electrician | 8 | 8 | 8 | 8 | — | 32 | $51.25 | $1,640.00 | $125.46 | $150.00 | $60.00 | $0.00 | $335.46 | $1,304.54 |
| James Kowalski | Electrician | 6 | 6 | 6 | 6 | 6 | 30 | $51.25 | $1,537.50 | $117.62 | $138.00 | $55.00 | $0.00 | $310.62 | $1,226.88 |
| Priya Nair | Electrician | — | — | 8 | 8 | 8 | 24 | $51.25 | $1,230.00 | $94.10 | $105.00 | $44.00 | $0.00 | $243.10 | $986.90 |
| Tom Becker | Laborer Mon & Fri; Electrician Tue–Thu (corrected — see Flags Memo) | 8 | 8 | 8 | 8 | 8 | 40 | $28.40 / $51.25 | $1,684.40 | $128.86 | $145.00 | $61.00 | $0.00 | $334.86 | $1,349.54 |
| Luis Herrera | Laborer | 8 | 8 | 8 | 8 | — | 32 | $28.40 | $908.80 | $69.52 | $68.00 | $30.00 | $0.00 | $167.52 | $741.28 |
| Sam Whitfield | Electrician Apprentice, Period 3 (registered) | 8 | 8 | 8 | 8 | 8 | 40 | $35.85 | $1,434.00 | $109.70 | $118.00 | $50.00 | $0.00 | $277.70 | $1,156.30 |
| Angela Brooks | Electrician | 8 | 8 | — | — | — | 16 | $51.25 | $820.00 | $62.73 | $72.00 | $29.00 | $0.00 | $163.73 | $656.27 |
| TOTALS — this project, this week | 254 | — | $11,304.70 | $864.82 | $1,001.00 | $411.00 | $25.00 | $2,301.82 | $9,002.88 | ||||||
Reconciliation: gross $11,304.70 − total deductions $2,301.82 = net $9,002.88. FICA is 7.65% of each worker's project gross, rounded half-up per worker. Becker's gross = 16 hrs × $28.40 (Laborer) + 24 hrs × $51.25 (Electrician) = $454.40 + $1,230.00 = $1,684.40. No worker exceeded 40 hours across all jobs this week, so no overtime premium applies to this payroll. Deductions shown are the portions allocated to earnings on this project.
(c) is elected for every worker on this payroll: fringe benefits are paid in cash, in full, as part of the rate of pay shown above. No payments are made to a bona fide fringe-benefit fund, trust or program for this project week (§(a) not elected), and no exception under §(b) is claimed. Apprentice Whitfield is registered in a bona fide apprenticeship program; certificate on file with the contractor.
I, [Name and title of the contractor's certifying official — e.g., Dana Whitaker, Owner], do hereby state:
(1) That I pay or supervise the payment of the persons employed by Summit Ridge Electrical LLC on the Riverside Elementary School Modernization project; that during the payroll period commencing October 26, 2026 and ending November 1, 2026, all persons employed on said project have been paid the full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said contractor 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 the Copeland Act regulations (29 CFR Part 3).
(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 or she performed.
(3) That any apprentices employed are duly registered in a bona fide apprenticeship program registered with a State apprenticeship agency recognized by the Bureau of Apprenticeship and Training, U.S. Department of Labor, or if no such recognized agency exists in a State, are registered with the Bureau of Apprenticeship and Training, U.S. Department of Labor.
(4) That: (a) where fringe benefits are paid to approved plans, funds or programs — not applicable this week; (b) where fringe benefits are paid in cash — each laborer or mechanic 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 Section 4(d); (c) where fringe benefits are paid as a combination — not applicable.
Signature: ______________________________________ Date: ______________
Why this page is unsigned in the demo: the certification is a legal attestation by the contractor. A done-for-you service prepares and checks the pack; it does not — and cannot — sign this statement for the client. See the Verification Memo and the Flags Memo: the $828.40 in corrections listed there must actually be paid to the workers before this statement can truthfully be signed.
Demo pack contents: 01-source-timesheet-as-received.csv · this file (02) · 03-flags-memo.md. All figures fictional and internally reconciled for demonstration.