Annual Payroll Report Operating As A Self Insurer{26C}

FORM 26C-7/6/2011 COMMONWEALTH OF VIRGINIA ICHMOND, VIRGINIA 232 ATTN: CHIEF FINANCIAL OFFICERAnnual Payroll Report of City, Town or County Operating as a Self-InsurerYear Ended December 31, Employer Pursuant to the provisions of Section 65.2-this report must be prepared upon a calendar year basis and filed with by March 15th. All salaries and wages paid or due officials and employees for the calendar year, together with other remuneration, if any, must be reported including amounts paid temporary and part-time employees irrespective of the type of work done. See notes on back. CLASSIFICATION OF OPERATIONS CLASS CODES Total Payroll for Twelve Mos. Ending December 31, Tree Pruning and Spraying, incl. Drivers 0106 Machine Shop 3632 Street or Road Construction, paving, resurfacing, incl. Drivers 5506 Street or Road Construction, clearing, excavation, incl. Drivers 5507 Sewer Construction, all operations, incl. Drivers 6306 Gas & Water Main & Connections - Construction, incl. Drivers 6319 Air craft Ground Employees 74 03 Gas Works, all operations (excl. co nstruction of bldgs/gas holders) 7502 Waterworks Operation, all employees, incl. Drivers 7520 Sewerage Disposal Plant Operation, incl. Drivers 7580 Garbage Works - Reduction or Incineration 7590 Firefighters, incl. Drivers 77 10 Law Enforcement Offi cers, incl. Drivers & Emergency Communication Technicians 7720 Automobile Repair Shops - all employees, incl. Drivers 8380 Engineers or Architects - not engaged in actual construction 8601 Clerical Office Employees (Court clerks, Comm. Atty., etc.) 8810 Dog Warden (kennel), incl. Drivers 8831 Hospital - Professional Employees 8833 Care, custody & maintenance of bldgs. & grounds 9015 Hospital - All employees other than professionals 9040 All other Library Employees 9101 Parks & Recreation Areas - All operations except new construction 9102 Cemetery Employees 9220 Sewer Cleaning, Street Cleaning, & Snow/Ice Removal & Drivers 9402 Garbage, Ashes or Refuse Collection, incl. Drivers 9403 Tax Collectors, Inspectors, Farm & Home Demonstration Agents 9410 Welfare, Case Workers - not office 9411 Space for other classifications available on reverse side Subtotal this page Subtotal 2 nd page Total of all payroll Signed this day by Date Signature of Representative and Title of Name and Address of City, Town or County Fed. Tax ID# This day personally appeared before me, acknowledged their signature, and made oath that the foregoing report is correct. Given under my hand and notarial seal this day of , . Signature of Notary SEAL My commission expires American LegalNet, Inc. www.FormsWorkFlow.com CLASSIFICATION OF OPERATIONS continued CLASS CODES PAYROLL AMOUNT Subtotal 2 nd page Note 1: The extra remuneration paid for overtime may be deducted; e.g. if time and a half paid for overtime, the half may be deducted. Note 2: New construction work and alterations done by employees of the municipality must be reported under the various construction classifications applicable, such as masonry, plumbing, sheet metal work, etc. Note 3: If you need to report for flying crew the Classification Code is 7421, however, when using 7421 you must also report the number of passenger seats using Classification Code 0088. Please enter the name and telephone number of the person to contact if we have any questions regarding this report. Please print. Name of Contact Telephone # American LegalNet, Inc. www.FormsWorkFlow.com