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U.S. Department of Labor PAYROLL <br /> Wage and Hour Division %VNI <br /> (For Contractor's Optional Use;See Instructions at www.dol.gov/whdMorms/wh347instr.htm) L-S.Wav,and Kwur Ur.raiout <br /> Persons are not required to respond to the c0lection of rntomnatron unless it displays a currently valid OMB control number. Rev.Dec.2008 <br /> NAME OF CONTRACTOR OR SUBCONTRACTOR ADDRESS PO Box 79O <br /> OMB No.:1236-0008 <br /> P <br /> McCollum's Excavating LLC <br /> Nederland,CO 80466 Ex Tres: 02/28/2018 <br /> PAYROLL NO. FOR WEEK ENDING PROJECT AND LOCATION PROJECT OR CONTRACT NO <br /> 1 10/21/2016 London Mine <br /> r <br /> (1) (2) (3) (4)DAY AND DATE (5) (6) (7) (9) <br /> i m ( DEDUCTIONS <br /> o Sa Su M Tu W Th F NET <br /> NAME AND INDIVIDUAL IDENTIFYING NUMBER o$n 15 16 17 1 g 19 20 21 GROSS WITH- WAGES <br /> (e g,LAST FOUR DIGITS OF SOCIAL SECURITY e WORK o TOTAL RATE AMOUNT HOLDING TOTAL PAID <br /> NUMBER OF WORKER i i W CLASSIFICATION HOURS WORKED EACH DAY OUR OF PAY EARNED FICA TAX OTHER DEDUCTIONS FOR WEEK <br /> Cindy McCollum Labor o S796 88 <br /> 4235 <br /> $61.12 5125 43 $]86.55 $610.33 <br /> 3 700 8.10 lu es 25.50 3125 <br /> Jacob Edwards Labor o 382.50 <br /> 1653 0 $29.26 $64.12 $93.38 $299.12 <br /> s 7 uD a sD to Du 25.50 151N1 <br /> Zach Hooker Labor fls <br /> $382.50 <br /> 21553 520.46 $13.25 $33.73 $348 77 <br /> i DO R% le Do 25.50 15•00 <br /> O <br /> S <br /> O <br /> S <br /> O <br /> 3 <br /> O <br /> S <br /> 0 <br /> 3 <br /> While Completion of Form WH-347 is optimal,0 is mandatory for covered contractors and subcontractors performing work on Federally financed or assisted construction contracts to respond to the.Information oollertlon contained in 29 C.F.R.§§3.3,5.5(a).The Copeland Act <br /> (40 U.S C.§3145)contractors and suboontl8dDrs performing work on Federally financed or assisted construction contracts to"furnish weekly a statement with respect to the wages paid each employee during the preceding week.' U.S.Department of Labor(DOL)regulations at <br /> 29 C.F.R §5 5(a)(3)(h)require Contractors to submit weekly a copy of all payrolls to the Federal agency Contracting for ar financing the construction project,accompanied by a signed"Statement of Compliance"indicating that the payrolls are Correct and Complete and that each laborer <br /> or mechanic has been pad not less than the proper Davis-Bacon prevalkng wage rate for the work performed.DOL and federal contracting agencies receiving this information review the information to determine that employees have received legally required wages and fringe benefits <br /> Public Burden Statement <br /> We estimate that is will take an average of 55 minutes to complete this collection,including time for reviewing Instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information.If you have <br /> any comments regarding these estimates or any other aspect of this collection,including suggestions for reducing this burden,send them to the Administrator,Wage and How Division.U S.Department of tabor,Room S3502,200 Constitution Avenue,N.W. <br /> Washington,D.0 20210 <br /> (over) <br />