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AND/OR EQUIP. LICENSE NO. CONTRACT NO. DAY AND DATE ST OR OT S O NOTE CERTIFICATION WILL BE ACCEPTED ONLY FROM THE CONTRACTOR EMPLOYING THE OWNER OPERATOR IT WILL NOT BE ACCEPTED FROM THE OWNER OPERATOR HIM / HERSELF* TOTAL WEEKLY HOURS HOURLY RATE OF PAY GROSS PAYMENT EARNED CHECK NO. Date do hereby state Name of signatory party Title 1 That I pay or supervise the payment of the persons reported on this form as Owner-operators by Contractor or subcontractor on the that during the payroll perio ...

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