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PAYROLLICERTIFIED STATEMENT FORM WH-38 <br />FOR USE IN COMPLYING WITH ORS 279C.845' <br />BUREAU OF.LABOR AND INDUSTRIES <br />WAGE AND HOUR DIVISION <br />_ .ARTC)R ❑ <br />Business Name <br />Project Name: <br />Mailing Address: <br />THI5 5r~ <br />Public Contracting Agency Name: <br />Phone: ( ) <br />Date Contract Specifications First Advertised for Bi : <br />Contract Amount: <br />0) i2) { { <br />AND CLASSIFICATION <br />NAME,ADDRESS (INCLUDE GROUP # <br />EMPLOYEE'S AND APPRENTICESHIP <br />IDENTIFICATION STEP IF APPLICABLE) <br />NUMBER <br />OT <br />ST <br />OT <br />ST <br />OT <br />ST <br />OT <br />ST <br />Q <br />Number: <br />Pro Location: <br />Project County: <br />Of <br />HOURS WORKED £ H ?Y <br />Subcontract /AmOu, n. <br />prime Contractor Business Name (DBA)• <br />Prime Contractor phone: ( Registration Number: <br />Prime contractor's CCB Reg (10) (111 <br />Da5e Youu Bed ork o Pr ° ect~8lg~ <br />HOURLY FRINGE NAME OF BENEFIT <br />HOURLY BENEFITS PAID PARTY, PLAN. <br />FRINGE GROSS ITEMIZED . NET WAGES TO BENEFIT FUND, OR <br />DEDUCTIONS PARTY, PLAN, PROGRAM <br />HOURLY BENEFIT AMOUNT FICA FED, PAID FUND, OR <br />TOTAL BASE AMOUNTS EARNED (see STATE ETC. PROGRAM <br />HOURS RATE PAID AS directions) <br />WAG ES TO <br />EMPLOYEE <br />1 <br />OT <br />ST j <br />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. <br />"Although this form <br />THIS FORM CONTlNIlEt? ON REVERS <br />WH-38 (Rev, 11-09) <br />