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~~~ ~2~ (3) DAY AND DATE (4) (S) (6) (~ (8) (9) (10) (11) NAME, ADDRESS AND SOCIAL SECURITV TpApE TOTAL ~5~ HOUfiLV FRINGE GROSS AMOUNT TOTAL DEWCTION NET WACaE PAID FOR HOURLY FRINGE BENEffT P D NAME OF 9ENEFIT NUMBER OF EMPLOVEE CLASSIFtG1TI0N fINCLVDE GROU I IF APP HOURS MOURIV RATE OF 89~IEFR PAID AS WAGE TO ~~ED flCA, FED. STATE ETC WEEK AI TO pqqTy, p~AN, PARTY, M.AN, FUND, OH LICA8LE1 HOURS WORKED EACH DAY PAY EMPLOYEE , . FUND OR PROGRAM PROGRAM OT S OT S OT S • OT S (NAME OF SIGNATORY PARTY) (TITLE) HEREBY STATE: (11 THAT I PAY OR SUPERVISE THE PAYMENT OF THE PERSONS E~APLOYED BY; ON THE (CONTRACTOR, SUBCONTRACTOR OR SURETY) (BUILDING OR WORK) THAT DURING THE PAYROLL PERIOD COMMENCING ON THE DAY OF , 19 , AND ENDING THE DAY OF , 19 ALL PERSONS EMPLOYED ON SAID PROJECT HAVE BEEN PAID THE FULL WEEKLY WAGES EARNED, THAT NO REBATES HAVE BEEN OR WILL BE MADE EITHER DIRECTLY OR iNDIRECTLY TO OR ON BEHALF OF SAID 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 DESCRIBED AS FOLLOWS: (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 IN THE CONTRACT; THAT THE CLASSIFICATION SET FORTH THEREIN FOR EACH WORKER CONFORMS 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 EXtSTS IN A STATE, ARE REGISTERED WITH THE BUREAU OFAPPRENTICESHIP 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 NOTE TO CONTR.4CTORS: YOU MUST ATTACH COPIES OF THIS FORM TO EACH OF YOUR PAYROLL SUBMISSIONS ON THIS PROJECT. SEE THE BOLI PUBLICATION pREVAILING WAGE RATES FOR PUBLIC WORKS CONTRACTS IN OREGON FOR INSTRUCTIONS ON COMPLETING THIS FORM. FILE THIS FORM WITH THE CONTRACTINC, AGENCY rr~n~~ ~nru ~fo ~DC~/ C/(1R1 srr . . .. . . .. . ... , ~ ~,~ . . ... . . . . . . .. ..~an.~~....,....-.w,,,,e,e.,,», ,~.»_...,,,., m.,........ .. ........ . .. . ..... .. .