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BUREAU OF LABOR AND INDUSTRIES <br />WAGE AND HOUR DIVISION <br />PRIME CONTRACTOR ^ <br />SUBCONTRACTOR ^ <br />CCB Registration Number: <br />Business Name (DBA): <br />Phone: ( ) <br />Street Address: <br />Mailine Address: <br />Project Location: <br />Project County: <br />Date Pay Period Began: Date Pay Period Ended: <br /> <br />THIS SECTION FOR PRIME CONTRACTORS ONLY <br />Public Contracting Agency Name: <br />Phone: ( ) <br />Date Contract Specifications First Advertised For Bid: <br />Contract Amount THIS SECTION FOR SUBCONTRACTORS ONLY <br />SubcontracS Amount: <br />Prime ConVactor Business Name (DBA): <br />Phone: ( ) CCB RegisVation Number: <br />Date You Be an Work On The Pra'ect: <br />(1) (2) (3) DAY AND DATE (4) (5) (6) (7) (8) (9) (10) (11) <br /> <br />NAME, ADDRESS AND <br />TRADE, 70TnL <br /> <br />HOURS BASIC <br /> <br />HOURLY HOURLV FRINGE <br />BENEFIT PAID AS GnOSS <br />AMOUNT TO7AL <br />DEDUCTION NE7 wpGE <br />PAID FOR HOURLY FRINGE <br /> <br />BENEFIT PAID T NAME OF BENEFIT PAR7Y, <br /> <br />PLAN, FUND, OR <br />SOCIAL SECURITY <br />NUMBER OF EMPLOYEE CLASSIFICATION <br />(INCLUDE GROUP RATE OF <br />PAY y~qGE TO <br />EMPLOYEE EARNED FICA, FED, <br />STATE, ETC WEEK PARTY, PLAN, <br />FUND OR PROGRAM <br /> ;t IF APPLICABLEI HOURS WORKED EACH DAY PaocRann , <br /> ~ <br /> OT <br /> <br /> S <br /> <br /> OT <br /> <br /> <br /> S <br /> <br /> OT <br /> <br /> S <br /> <br /> OT <br /> <br /> <br /> S <br />PAYHOLUCEHTIFIED STATEMENT FORM WH-38 <br />FOR USE IN COMPLYING WfTH ORS 279.364 <br />FIRST ^ 90 DAY ^ LAST ^ <br />Project Name: <br />Project Number: <br />Of Work: <br />THIS FORM CONTINUED ON REVERSE <br />FORM WH-38 (REV. 6/96) <br />