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M NH-38 <br />IEDSTATEMENT,FOR <br />TH ORS 279C.8~5~ <br />FFAyROLLjCERTIF OR USE IN COMPLYING'WITH ORS 279C.8~5~ <br />BUREAU OF LABOR AND INDUSTRIES <br />WAGE AND HOUR DIVISION <br />Mailing Address: <br />public Contracting Agency Name <br />phone first <br />pate Contract Specie{cations Advertised for Bid'. <br />) <br />Contract Amount' <br />{2) I~ <br />TRADE, <br />CLASSIFICATION # AND <br />NAME AND ADDRESS QN pRPN'nCESNIP STEP <br />OF EMPLOYEE AP. tF APPLICABLE) <br />OT <br />ST <br />OT <br />ST <br />OT <br />ST <br />OT <br />HOURS <br />Of <br />project County' <br />bconount: pBA): <br />SuPrime Contractor BUSIness Name <br />n Number: <br />Prime Contractor Phone*( ) . <br />Prime Contractor s o k on the proistratroecs: <br />pate You Be an W T <br />6 <br />4 <br />6 <br />HOURLY <br />ITEMIZED <br />NET <br />WAGES <br />BASE <br />FRINGE GROSS <br />BENEFIT AMOUNT <br />DEDUCTIONS <br />FICA FED, STATE, <br />PAID <br />FOR <br />WEEK <br />HOURLY <br />TOTAL RATE <br />AMOUNTS EARNED , <br />PAID AS <br />ETC. <br />HOURS OF PAY <br />WAGES TO <br />EMPLOYEE <br />HOURLY FRINGE <br />NEFITS PA TO <br />NAME OF BENEFIT <br />FUND,OR <br />N <br />R <br />PARTY <br />BE <br />BENEFIT PARTY , <br />FUND, OR <br />P <br />GO <br />RAM <br />PLAN, <br />PROGRAM <br />ST <br />con Act. <br />OT <br />state PWR law and the federal Daws <br />the -Ba <br />ST meet the rQQuirements of both <br />the U.S. Depa>~ent of Labor, it is designed to a <br />THIS FORM CONTINUED ON REVERSE <br />'Although this farm has not been officially pProved by <br />WH-38 (Rav. 01.09) <br />