Fillable Public Works Payroll Reporting Form (A- 1-131 - California ... - dir ca
California Department of Industrial Relations
PUBLIC WORKS PAYROLL REPORTING FORM
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CONTRACTOR'S LICENSE NO.: SPECIALITY LICENSE NO.: ADDRESS:
NAME OF CONTRACTOR: OR SUBCONTRACTOR: PAYROLL NO.: (4) (1) NAME, ADDRESS AND SOCIAL SECURITY NUMBER OF EMPLOYEE (2)
NO. OF WITHHOLDING EXEMPTIONS
FOR WEEK ENDING: DAY M T W TH DATE F S S TOTAL HOURS HOURLY RATE OF PAY (5) (6)
SELF-INSURED CERTIFICATE NO.:...
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