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Date: <br />I (TITLE) <br />(NAME OF SIGNATORY PARTY) by <br />do hereby state: <br />or supervise the payment of the persons employed <br />;TATEMENI <br />ect to the federal <br />completing sections (1) .(3), if your project is subject subj as well: <br />In addition to complete the following <br />Davis-Bacon Act requirements, (4) That: <br />BENEFITS ARE PAID TO APPROVED PLANS, FUNDS O <br />a WHERE FRINGE <br />PROGRAMS <br />In addition to the basic hourly wage rates paid to each I listed in the above referenced payroll, payments of fringe <br />rams for the benefit <br />below. Programs <br />the contract ha except as noted an section 4(c)ro appropriate <br />such employees, <br />(b) WHERE FRINGE BENEFITS ARE PAID IN CASH <br />Each laborer or mechanic listed in the above reference payroll has been paid, <br />as indicated on the payroll, an amount not less than the sum of the applicable <br />p _ as fisted <br />basic hourly wage rate plus the amount of the rbelowcl fringe . benefits <br />the contract, except as noted in Section 4(c) <br />(1) That p Y <br />(CONTRACTOR, SUBCONTRACTOR ORS during the payroll period <br />on the (BUILDING OR WORK) and ending the day <br />commencing on the day °f AE R <br />(MONTH) aid the <br />all persons employed on said project have been p <br />of (MONTH) (YEAR) <br />full weekly wages earned, that no rebates have been or Will be made either directly Or <br />indirectly to or on behalf of said (CONTRACTOR, SUBCONTRACTOR OR SURETY) <br />S earned by any person, and that no any other than <br />from the full weekly wage indirectly from the full wages earned by Y P <br />Regulations, a <br />deductions as specified in ORS 652.610, and as defined in, <br />made either directly or reta of Labor under the Coplan 276), <br />c and <br />permissible <br />3 (29 CFR Subtitle t 948563 Stat. 08572 StatY967; 76 Stat. 357; 40 U.S.C. amended (48 Sta <br />described below: <br />above <br />at an payrolls otherwise under thiscnteract ates for workers required to be contained submitted for the therein are <br />(2) Th Y <br />period are correct and complete; that the wage <br />applicable wage rates contained in any wage determination <br />less than the app <br />incorporated into the contract; that the classifications set forth therein for each worker <br />conform with work performed. <br />in the above period are duly registered in iza bona ed by the <br />a rentices employed renticeship ag recog <br />p <br />(3) That any pp ro rani registered with a state app such <br />apprenticeship p g renticeship <br />Bureau of Apprenticeship and Training United <br />s esta withDthe Bureau°° <br />recognized Appr, or if no <br />agency exists in a state, are <br />tates Department of Labor. <br />and Training, United S- ENT, KNOW THE CONTENTS THEREOF <br />I HAVE: AND IT S TRUE TO MY KNOWLEDGE. <br />(NAME - - IT LE) <br />REMARKS <br />SIGNATURE <br />i NAME AND TITLE <br />WILLFUL FALSIFICATION OF AuYBC 1 THE SUBCONTRACTOR VE 5TATEMENTSO E <br />TO CIVIL OR CRiMiTI <br />TLE 31 <br />SUBJECT THE CONTRACTOR OR S <br />PROSECUTION. SEE SECTIIO1001 OF TITLE 18 AND SECTION 23 <br />OF THE UNITED STATES CODE. <br />SIGNATURE AND DATE <br />FORM WITH THE. PUBLIC AGENCY ASSOCIATED WITH THE PROJECT <br />FILE THIS HIS PROJEC T. <br />TO EACH OF YOUR PAYROLL REGOMISSIONS ON T <br />N GOVIBOLI. <br />ONOTE TO CONTRACTORS: YOU MUST ATTACH COPIES OF THIS FOR <br />AND ADDITIONAL FORMS ARE AVAILABLE ON.OUR Nâ–șEBSITE: <br />INSTRUCTIONS <br />(c) EXCEPTIONS. <br />11 <br />