A real sample report

Generated for a fictional Ohio electrical subcontractor from the real OH20260001 wage determination, modification 4 — by the same pipeline that prepares paying customers' reports. This is exactly what you download, sign, and send to your GC's compliance coordinator.

Page 1, the payroll grid: Vasquez Electric LLC, week ending 2026-08-23, three electricians under wage determination OH20260001 mod 4, each with daily hours, straight-time and overtime rates of 43.00 and 64.50, gross pay, deductions and net wages. — Page 1 — the payroll grid.

Page 2, the Statement of Compliance in the name of Maria Vasquez, office manager, with box 4(a) checked because fringe benefits are paid to approved plans, exceptions none, with the signature line left blank for the contractor. — Page 2 — the Statement of Compliance you sign.

Download the sample PDF

What's on it

The payroll grid — one row per worker: name and ID last-4, classification exactly as the wage determination words it, daily straight-time and overtime hours, rates, gross, each deduction your payroll computed, and net.
The Statement of Compliance — the page you sign. The fringe-benefit question (4(a) plans, 4(b) cash, or both) is answered to match how this contractor actually pays fringes, with the exception notes filled in.
Provenance on the form — the pinned determination's number and modification appear on the report, so the coordinator can check the rates against the same document you used.

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