BOLI WH38~1.pdf

BUREAU OF LABOR AND INDUSTRIES PAYROLL/CERTIFIED STATEMENT FORM WH-38

WAGE AND HOUR DIVISION FOR USE IN COMPLYING WITH ORS 279C.845*

PRIME CONTRACTOR SUBCONTRACTOR PAYROLL NO.________________________ FINAL PAYROLL

Business Name (DBA): Phone: ( ) CCB Registration Number:

Project Name: Project Number: Type of Work:

Street Address:

Mailing Address:

Project Location:

Project County:

Date Pay Period Began: Date Pay Period Ended:

THIS SECTION FOR PRIME CONTRACTORS ONLY THIS SECTION FOR SUBCONTRACTORS ONLY

Public Contracting Agency Name:

Phone: ( ) Date Contract Specifications First Advertised for Bid:

Contract Amount:

Subcontract Amount:

Prime Contractor Business Name (DBA):

Prime Contractor Phone: ( ) Prime Contractor’s CCB Registration Number:

Date You Began Work on the Project:

(1) (2) (3) DAY AND DATE (4) (5) (6) (7) (8) (9) (10) (11)

NAME, ADDRESS AND

EMPLOYEE’S

IDENTIFICATION

NUMBER

CLASSIFICATION

(INCLUDE GROUP #

AND APPRENTICESHIP

STEP IF APPLICABLE)

TOTAL

HOURS

HOURLY

BASE

RATE

HOURLY

FRINGE

BENEFIT

AMOUNTS

PAID AS

WAGES TO

EMPLOYEE

GROSS

AMOUNT

EARNED (see directions)

ITEMIZED

DEDUCTIONS

FICA, FED,

STATE, ETC.

NET WAGES

PAID

HOURLY FRINGE

BENEFITS PAID

TO BENEFIT

PARTY, PLAN,

FUND, OR

PROGRAM

NAME OF BENEFIT

PARTY, PLAN,

FUND, OR

PROGRAM

HOURS WORKED EACH DAY

OT

ST

Schedule: 5/8 4/10 ; Reg. Hrly. Schd:to.

OT

ST

Schedule: 5/8 4/10 ; Reg. Hrly. Schd:to.

OT

ST

Schedule: 5/8 4/10 ; Reg. Hrly. Schd:to.

OT

ST

Schedule: 5/8 4/10 ; Reg. Hrly. Schd:to.

OT

ST

Schedule: 5/8 4/10 ; Reg. Hrly. Schd:to.

*Although this form has not been officially approved by the U.S. Department of Labor, it is designed to meet the requirements of both the state PWR law and the federal Davis-Bacon Act.

WH-38 (Rev. 05/16) THIS FORM CONTINUED ON REVERSE sharmanm Sticky Note Marked set by sharmanm sharmanm Sticky Note Marked set by sharmanm sharmanm Sticky Note Marked set by sharmanm

CERTIFIED STATEMENT

Date:

I, , (NAME OF SIGNATORY PARTY) (TITLE)

do hereby state:

(1) That I pay or supervise the payment of the persons employed by:

(CONTRACTOR, SUBCONTRACTOR OR SURETY)

on the ; that during the payroll period

(BUILDING OR WORK)

commencing on the day of , , and ending the day

(MONTH) (YEAR)

of , , all persons employed on said project have been paid the

(MONTH) (YEAR)

full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said

(CONTRACTOR, SUBCONTRACTOR OR SURETY)

from the full weekly wages earned by any person, and that no deductions have been made either directly or indirectly from the full wages earned by any person, other than permissible deductions as specified in ORS 652.610, and as defined in Regulations, Part 3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967; 76 Stat. 357; 40 U.S.C. 276c), and described below:

(2) That any payrolls otherwise under this contract required to be submitted for the above period are correct and complete; that the wage rates for workers contained therein are not less than the applicable wage rates contained in any wage determination incorporated into the contract; that the classifications set forth therein for each worker conform with work performed.

(3) That any apprentices employed in the above period are duly registered in a bona fide apprenticeship program registered with a state apprenticeship agency recognized by the Bureau of Apprenticeship and Training, United States Department of Labor, or if no such recognized agency exists in a state, are registered with the Bureau of Apprenticeship and Training, United States Department of Labor.

I HAVE READ THIS CERTIFIED STATEMENT, KNOW THE CONTENTS THEREOF

AND IT IS TRUE TO MY KNOWLEDGE:

(NAME AND TITLE)

(SIGNATURE AND DATE)

In addition to completing sections (1) - (3), if your project is subject to the federal Davis-Bacon Act requirements, complete the following section as well:

(4) That:

(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS OR

PROGRAMS

- In addition to the basic hourly wage rates paid to each laborer or mechanic listed in the above referenced payroll, payments of fringe benefits as listed in the contract have been or will be made to appropriate programs for the benefit of such employees, except as noted in Section 4(c) below.

(b) WHERE FRINGE BENEFITS ARE PAID IN CASH

- Each laborer or mechanic listed in the above referenced payroll has been paid, as indicated on the payroll, an amount not less than the sum of the applicable basic hourly wage rate plus the amount of the required fringe benefits as listed in the contract, except as noted in Section 4(c) below.

(c) EXCEPTIONS:

EXCEPTION (CRAFT) EXPLANATION

REMARKS:

NAME AND TITLE SIGNATURE

THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY

SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL

PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31

OF THE UNITED STATES CODE.

FILE THIS FORM WITH THE PUBLIC AGENCY ASSOCIATED WITH THE PROJECT

NOTE TO CONTRACTORS: YOU MUST ATTACH COPIES OF THIS FORM TO EACH OF YOUR PAYROLL SUBMISSIONS ON THIS PROJECT.

INSTRUCTIONS AND ADDITIONAL FORMS ARE AVAILABLE ON OUR WEBSITE: WWW.OREGON.GOV/BOLI.

WH-38 (Rev. 05/16)