Purpose

The Statement of Compliance certifies that the information contained on the payroll report is true and correct. The Statement shall have an affirmation of a “certifying person”, whom is a person with authority1 (i.e. contractor’s human resource department) a person with the ability to affirm the certification, under the penalty of perjury the records are originals, or, are true and correct copies of the original.

Instructions

1. Complete the top portion:
   • Contractor / Subcontractor: Type in the name of the company that is furnishing said payroll report
   • Contract Number: Type in the contract number as provided by “Owner” of project.
   • The First and Last Date of Pay Period: Note – This will be the same as the corresponding Certified Payroll Report (“CPR”). Spell out the Month, and type in the number of the day (D) and year (YYYY).
2. Thoroughly read through Item (1) and verify that the following statements have been complied with by the “certifying person” before moving onto Item No. (2).
3. Thoroughly read through Item (2) and verify that the following statements have been complied with by the “certifying person” before moving onto Item No. (3).
4. Check the applicable box (or boxes) for how Fringe Benefits are paid under Item (3). This is the “Method of Distributing Fringe Benefits”:
   • Box (a) Fringe Benefits are paid to approved plans, such as a labor union.
   • Box (b) Fringe Benefits are paid directly to the employee. For example, a check was made payable to the employee for the distribution of fringe benefits.
   • Box (c) Exceptions may include an additional annuity fund through the labor union, additional amounts the employee requests to be taken out, or Training Fund Contributions that are paid directly to the Apprenticeship Council (i.e. CAC).
5. If there are any “exceptions” from any of the (3) options as described in Item 3 (instruction number 4), the Exception(s) are noted here with an Explanation:
   • Provide the Craft that the Exception pertains to in the column provided (ie: Laborer: Groups 1-5).
   • Provide in the Explanation column next to the craft listed, the hourly amount that is an exception to Box (a) or (b) and where it is being paid to.
6. Sign and Date the form in order to complete the Statement of Compliance by doing the following:
   • Type (or print) the Name of the Certifying Person (First and Last name)
   • Provide the Title of the Certifying Person
   • Have the Certifying Person Sign and Date the form to complete

Other Helpful Information

A Statement of Compliance is required with every certified payroll report. Each payroll report shall not include more than seven consecutive days.

Web link to form: https://www.dot.ca.gov/hq/construc/forms/cem2503.pdf