Subcontractor Payroll Statement

SUBCONTRACTOR PAYROLL STATEMENT

Project:   Prime Contractor / Client:

Personal & Company Information

Engagement / Position Information

Pay Period: From to   Pay Rate (per hour or unit):

Payment Terms:    Timesheet(s) attached:

Work Log — Itemized Earnings

Enter each line of work performed during the pay period. Amounts should reflect billed amounts for services rendered.

Expenses / Reimbursements (Itemize)

Receipts attached:   Invoice / Attachment ID:

Deductions & Tax Acknowledgment

The subcontractor affirms they are an independent contractor and are solely responsible for all federal, state, and local taxes, insurance, and benefits. No withholdings are made by the prime contractor unless required by law. Check applicable entity type(s):

Individual / Sole Proprietor    LLC    Corporation

Certifications & Declarations

By signing below, the subcontractor certifies under penalty of perjury that the hours, rates, and amounts set forth in this statement are true, accurate, and represent work actually performed by the subcontractor or its authorized personnel for the referenced project and pay period. The subcontractor further certifies that it is properly licensed and insured to perform the work claimed, that it will maintain all required insurance and workers' compensation coverage, and that it will indemnify and hold harmless the prime contractor and client from any claims arising out of subcontractor's performance or failure to pay required taxes, wages, or benefits to its employees or subcontractors.

The subcontractor authorizes the prime contractor to verify work performance by contacting on-site managers and to perform verification checks necessary to validate this payroll statement. Authorization for background screening or prior-employer verification is granted where permitted by law. The subcontractor agrees that submission of this form and any attached timesheets constitute a request for payment and may be treated as an invoice for services rendered.

Employment History (for subcontractor record)

Employer 1

Employer 2

Education

Professional References

Reference 1

Reference 2

Reference 3

Legal Disclosures

Equal Opportunity: The prime contractor maintains an equal opportunity policy. This payroll statement does not alter either party's contractual obligations or the subcontractor's status as an independent contractor.

Confidentiality: Information contained in this payroll statement may be used for payment processing and compliance review. The parties agree to safeguard any sensitive financial or personnel information in accordance with applicable law.

Authorization & Applicant Certification

I certify that all information in this Subcontractor Payroll Statement and any attached documentation is true, complete, and accurate. I understand that submission of false information may result in denial of payment and recovery of any amounts paid, and may subject the subcontractor to civil or criminal penalties. I authorize the prime contractor and its designated agents to contact references, prior employers, and project representatives to verify information provided and to conduct any background or verification checks permitted by law.

I further certify that all personnel performing work under this subcontract are properly classified, that prevailing wage and certified payroll requirements (if applicable) are met, and that any certified payroll documents accompany this statement where required by contract.

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