Form DC-127   12/29/2011

NEW JERSEY DEPARTMENT OF TRNSPORTATION
MONTHLY CERTIFICATION OF CONTRACTOR’S PAYROLLS
SEE REVERSE SIDE FOR INSTRUCTIONS
PROJECT 
 NAME:	     	FEDERAL
 PROJECT NO:	     	DP NO:	     	
NAME OF EMPLOYER	CONTRACTOR	SUBCONTRACTOR	DATE OF 
LAST
PAYROLL
PRIOR TO
THIS REPORT	DATES OF PAYROLLS VERIFIED BY THIS REPORT	NUMBER OF WAGE RATE INSPECTION SUBMITTED W/THIS REPORT	
     			     	     	     	     	     	     	     	     	
     			     	     	     	     	     	     	     	     	
     			     	     	     	     	     	     	     	     	
     			     	     	     	     	     	     	     	     	
     			     	     	     	     	     	     	     	     	
     			     	     	     	     	     	     	     	     	
     			     	     	     	     	     	     	     	     	
     			     	     	     	     	     	     	     	     	
     			     	     	     	     	     	     	     	     	
     			     	     	     	     	     	     	     	     	
     			     	     	     	     	     	     	     	     	

I certify that, to the best of my knowledge all employees working on this project during this period have been included on a payroll and all payrolls listed above, have been verified, reviewed and accepted in accordance with contract requirements. 

		_______________________________________________________________		_____________________________	
					RE  (Signature)						Date

INSTRUCTIONS

List the names of each employer for which payrolls were received and reviewed.

Check whether the employer is the Contractor or a Subcontractor.

				Show the week ending date of the payroll which was last verified, if any for each employer.

				List the week ending dates of each payroll being verified as received and reviewed for the month.

				Show the number of Wage Rate inspections which have been completed and are being submitted with this report.  
Note:  One Wage Rate Inspection is interpreted to mean the interviewing of one (1) employee.