EMPLOYEE'S RESTITUTION RECEIPT

Contract No. __________________________  Prime Contractor

Subcontractor__________________________ Date

Amount of gross wages earned for hours indicated above in accordance 
with Contract rates:________________

Amount of wages actually received for hours indicated above:_______________

Gross amount of Wage Restitution due:_________________

I, the employee named above, do hereby certify that I have received wage restitution 
due as follows:
                         Gross Amount:_________________

 Less Legal Payroll Deductions:_________________

                    Net Pay Received:_________________

The above represents full restitution for the hours indicated above.

                                                                           Signature of Employee:__________________

As representative of the above named (Contractor or Subcontractor), I do hereby certify that payment has been made to the above employee for wages due as indicated above.

                                                                                                    Signature__________________

                                                                                                        Title____________________

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Last modified: February 08, 2001