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Bureau of Labor and Industries <br />Prevailing Wage Rate Unit <br />800 N.E. Oregon St., # 32 <br />Portland, OR 97232 . <br />phone: (503) 731-4074, ext.:250 <br />FAX: (503) 731-4623 <br />THIS FORM TO BE IISED FOR RECONCILIATION OF FEES ON COMPLETION OF <br />PIIBLIC WORICS PROJSCTS <br />(As required by ORS 279.375 and OAR 839-16-210) <br />Contractors: Please complete and mail this form to BOLI at the above address, after <br />completion of the public works project and not less than 30 days after the final <br />payment by the contracting agency. Contractors are required to determine the final <br />contract price, including all change orders or other adjuatments to the original <br />contract price and to calculate the adjusted prevailing wage rate fee, based on the <br />revised contract price. Documentation must be included to support the final contract <br />price. The prevailing wage rate fee, .001, (1/lOth of it) shall be applied to the <br />final contract price, with credit taken for fe~s already submitted. The contractor <br />must submit the additional fee payable to BOLI with the adjustment form or requests <br />for refund if applicable. **^ ~TTTTTAIJST. FEE WILL BE CAARGED, NOR A <br />°~~;~ MADE ON ANY RECONCILED AMnTT~'S UNDER 5~ 00 00 . <br />BIISIN88S NAMB (DBA) C~ ~ <br />MAILING 1-DDRS88s PHON$: ( ) <br />(STRBST OR PO BOX ~, CITY, STATB, ZIP) <br />PROJECT NAMB: <br />PROJBCT NIIId88R: PROJSCT LOCATION: <br />AC3ffi~TCY AW]1RDINt3 CONTRACT : DATB AWARDBD : <br />FINAL CONTRACT AMOIINT: FINAL FgS DIIB*: <br />(Include all change orders and adjustments ~(Final Contract amount X.001) <br />to the contract price) <br />ORIGINAL CONTRACT AMOIINT: <br />BALANCB DII$: <br />Sample Calculation: <br />INITIAL F88 PAID*: _ <br />+~(Contract amount X .001) <br />R$FUND DIIB: <br />(Final contract fee less initial fee paid) <br />Final Contract Amount: $400,000.00 Final Fee Due: $400.00 <br />Original Contract Amt: -300.000.0o Initial Fee Paid: -300.00 <br />Total Adjuatment: $100,000.00 Amount Due os Refund Due: $100.00 <br />*Documentation may conaiat of change ordera or other contract documents substantiating <br />the amount of the contract. <br />it/ii/fa aosrss.wc (Please dupliaata thi~ foro Lor future use) <br />