Form DC-128  12//29/2011

NEW JERSEY DEPARTMENT OF TRANSPORTATION
QUARTERLY SUMMARY OF CONTRACTOR’S PAYROLLS

      QUARTER  CY 20     

	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 SUBMITTED WITH THIS REPORT
(ATTACH PAYROLLS)	NUMBER OF WAGE RATE INSPECTIONS (EMPLOYEES INTERVIEWED)  THIS MONTH	

     			     	     	     	     	     	     	     	     	     	
				     	     	     	     	     	     	     	     	

     			     	     	     	     	     	     	     	     	     	
				     	     	     	     	     	     	     	     	

     			     	     	     	     	     	     	     	     	     	
				     	     	     	     	     	     	     	     	

     			     	     	     	     	     	     	     	     	     	
				     	     	     	     	     	     	     	     	

     			     	     	     	     	     	     	     	     	     	
				     	     	     	     	     	     	     	     	
     			     	     	     	     	     	     	     	     	     	
				     	     	     	     	     	     	     	     	
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 submitted herewith comply with the requirements of the Project’s Specifications, except as noted (attach explanatory memorandum).  Furthermore, I certify that the Contractor has the required posters displayed in conspicuous locations.	TOTAL WAGE RATE
INSPECTIONS THIS QUARTER	     	
     					
NAME		RE (Signature)			

INSTRUCTION

List the names of each employer for which payrolls are being forwarded with this summary.

Check whether the employer is the Contractor or a Subcontractor.

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

List the week ending dates of each payroll which is being submitted with this report.

Show the number of Wage Rate inspections which were made during this month for each employer.
A Wage Rate Inspection is interpreted to mean interviewing one (1) employee.