1. (a) Reporting Format. The format for reporting of payroll records requested pursuant to Labor Code Section 1776 shall be on a form provided by the public entity. Copies of the forms may be procured at any office of the Division of Labor Standards Enforcement (DLSE) throughout the state and/or:

   1. (b) Words of Certification. The form of certification shall be as follows: I, __________(Name-print) the undersigned, am __________(position in business) with the authority to act for and on behalf of__________, (name of business and/or contractor) certify under penalty of perjury that the records or copies thereof submitted and consisting of __________ (description, no. of pages) 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. Date:__________-___Signature:____________________ A public entity may require a more strict and/or more extensive form of certification.

   Division of Labor Statistics & Research P.O. Box 603 San Francisco, CA 94101

   ATTENTION: Prevailing Wage Unit

   Acceptance of any other format shall be conditioned upon the requirement that the alternate format contain all of the information required pursuant to Labor Code Section 1776. If, however, the contractor does not comply with the provisions of Labor Code Section 1776, the Labor Commissioner may require the use of DIR's suggested format, “Public Works Payroll Reporting Form” (Form A-1-131).

Note: Authority cited: Sections 54 and 1773.5, Labor Code. Reference: Section 1776, Labor Code.