Public Works Payroll Reporting Form {A-1-131}

California . . . . Department of Industrial Relations Defendant(s) : . . . . . . . . . . .PUBLIC .WORKS. PAYROLL. REPORTING ......... ......... ............ ...... FORM Page ______ of ______ ADDRESS: NAME OF CONTRACTOR: OR SUBCONTRACTOR: PAYROLL NO.: (4) (1) NAME, ADDRESS AND SOCIAL SECURITY NUMBER OF EMPLOYEE (2) NO. OF WITHHOLDING EXEMPTIONS CONTRACTOR'S LICENSE THE PEOPLE OF THE STATE OF NEW YORK NO.: SPECIALITY LICENSE NO.: FOR WEEK ENDING: TO DAY M T W TH F S S TOTAL HOURS HOURLY RATE OF PAY (5) (6) SELF-INSURED CERTIFICATE NO.: WORKERS' COMPENSATION POLICY NO.: (7) GROSS AMOUNT EARNED PROJECT OR CONTRACT NO.: PROJECT AND LOCATION: (8) DEDUCTIONS, CONTRIBUTIONS AND PAYMENTS (9) NET WGS PAID FOR WEEK CHECK NO. (3) WORK CLASSIFICATION DATE GREETINGS: HOURS WORKED EACH DAY S WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court FED. FICA STATE VAC/ HEALTH located at THIS ALL County of SDI PENSION TAX (SOC. SEC.) TAX HOLIDAY & WELF. PROJECT PROJECTS in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the TRAING. FUND ADMIN DUES TRAV/ SUBS. SAVINGS OTHER* TOTAL DEDUCTIONS O Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a FED. maximum penaltySTATE of $50 and all damagesHEALTH sustained as a FICA VAC/ THIS ALL SDI PENSION TAX (SOC. SEC.) TAX HOLIDAY & WELF. result of your failure to comply. PROJECT PROJECTS Witness, Honorable Court in County, , one of the Justices of the day of , 20 TRAING. FUND ADMIN DUES TRAV/ SUBS. SAVINGS OTHER* TOTAL DEDUCTIONS S O THIS PROJECT S ALL PROJECTS FED. TAX FICA STATE VAC/ (Attorney must sign above and type HOLIDAY HEALTH name below)WELF. SDI (SOC. SEC.) TAX & PENSION TRAING. Attorney(s) for FUND DUES ADMIN TRAV/ SUBS. SAVINGS OTHER* TOTAL DEDUCTIONS O THIS PROJECT S ALL PROJECTS FED. TAX Office and P.O. Address TRAV/ SUBS. FICA (SOC. SEC.) STATE TAX SDI VAC/ HOLIDAY HEALTH & WELF. PENSION O S = STRAIGHT TIME Form A-1-131 (New 2-80) O = OVERTIME SDI = STATE DISABILITY INSURANCE Telephone No.: ADMIN Facsimile No.: E-Mail Address: Mobile Tel. No.: *OTHER ­ Any other deductions, contributions and/or payments whether or not included or required by prevailing wage determinations must be separately listed. Use extra sheet(s) if necessary TRAING. FUND DUES SAVINGS OTHER* TOTAL DEDUCTIONS CERTIFICATION MUST be completed (See reverse side) American LegalNet, Inc. www.USCourtForms.com NOTICE TO PUBLIC ENTITY For Privacy Considerations Fold back along dotted line prior to copying for release to general public (private persons). (Paper Size then 8-1/2 x 11 inches) COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. I, (Name ­ print) -against- Plaintiff(s) : : , the undersigned, am the JUDICIAL SUBPOENA with the authority to act for and on behalf of (Position in business) (Name of business and/or contractor) : : Defendant(s) : ...................................................... , certify under penalty of perjury that the records or copies thereof submitted and consisting of (Description, number of pages) THE PEOPLE OF THE STATE OF NEW YORK TO are the originals or true, full, and correct copies of the originals which depict the payroll record(s) of the actual disbursements by way of cash, check, or whatever form to the individual or individuals named. GREETINGS: Date: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Signature: , the Honorable at the Court located at County of in room A public, entity may require a stricter and/or more extensive form of certification. at any recessed on the day of , 20 , at o'clock in the noon, and or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com