SCHEDULE OF WITHHOLDINGS UNDER THE DAVIS-BACON ACT (40 U.S.C. 276a)

AND/OR

THE CONTRACT WORK HOURS AND SAFETY STANDARDS ACT (40 U.S.C.327-333)

TO THE CLAIMS DIVISION

U.S. GENERAL ACCOUNTING OFFICE

WASHINGTON, D.C. 20548

Contractor or subcontractor charged
 with violations ………………………………………………………………………………………………………………………………………………………

Prime contractor ……………………………………………………………………………………………………………………………………………………

Contract No. ……………………………………………………………. ,

……………………………………………………………………………
(Date)

Report concerning irregularities transmitted to--

………………………………………………………………………………… ,

………………………………………………………………………………
(Date)

Deducted from amounts otherwise due the contractor, for deposit to the account "05X6022," covering wages due the employees whose names, social secuirty numbers, and current addresses are listed on the attached schedule, are withholdings pursuant to the following laws:

Davis-Bacon Act ………………………………………………………………………………

$ …………………………………………………

Contract Work Hours and Safety Standards Act ……………………………

$ …………………………………………………

Total ………………………………………………………………………………………

$ …………………………………………………

Forwarded herewith is check No.  ………………………………………………… ,

dated …………………………………………

for $ …………………………………………

………………………………………………………………………...................
(Disbursing officer or other administrative official)

Standard Form 1093

October 1971

4 GAO 46