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{1) (2) (3) DAY AND DATE (4) (5) (6) (7) (8) (9) (70) (1'1) <br />NAME, ADDRE55 AND <br />CIAL SECURITY TRADE, TOTAL BASIC <br />HOURLY HOURLY FRINGE <br />BENEFIT PAID AS GROSS <br />AMOUNT TOTAL <br />DEDUCTION NET WAGE <br />PAIO FOR HOURLY FRINGE <br />gENEF1T PAID TO NAME OF BENEFIT <br />PARTY, PLAN. FUND, <br />SO <br />NUMBER OF EMPLOYEE CLASSIFICATION <br />(INCLUDE GROU HOURS <br />RATE OF <br />Y <br />WAGE TO <br />EMPLOYEE EARNED FICA, FED, <br /> <br />STATE, ETC. WEEK <br />PARTY, PLAN, <br />FUND OR <br />OR <br />PROGRAM <br /> N IF APPLICABIE) HOURS WORKED EACH DAY PA PROGRAM <br /> <br /> OT <br /> <br /> S <br /> <br /> OT <br /> S <br /> <br /> <br /> OT <br /> <br /> <br /> S <br /> <br /> OT <br /> <br /> <br /> S <br />O HEREBY STATE: <br />(NAME OF SIGNATORY PARTY) (TITLE) <br />(1) THAT I PAY OR SUPERVISE THE PAYMENT OF THE PERSONS EMPLOYED BY; <br />N THE <br />(CONTRACTOR, SUBCONTRACTOR OR SURETY) (BUILDING OR WORK) <br />THAT DURING THE PAYROLL PERIOD COMMENCING ON THE DAY OF , 19 , AND ENDING THE DAY OF , 19 <br />ALL PERSONS EMPLOYED ON SAID PROJECT HAVE BEEN PAID THE FULL WEEKLY WAGES EARNED, THAT NO REBATES HAVE BEEN OR WILL BE MADE EITHER DIRECTIY OR INDIRECTLY <br />TO OR ON BEHALF OF SAID FROM THE FULL WEEKLY WAGES EARNED BY ANY PERSON, AND THAT NO DEDUCTIONS HAVE BEEN MADE EITHER <br />DIRECTLY OR INDIRECTLY FROM THE FULL WAGES EARNED BY ANY PERSON, OTHER THAN PERMISSIBLE DEDUCTIONS AS SPECIFIED IN ORS S52.610, AND DESCRIBED AS FOLLOWS: <br />(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 <br />WORKERS CONTAINED THEREIN ARE NOT LESS THAN THE APPLICAB~E WAGE RATES CONTAINED IN ANY WAGE DETERMINATION INCORPORATED IN THE CONTRACT; THAT THE <br />CLASSIFICATION SET FORTH THEREIN FOR EACH WORKER CONFORMS WITH WORK PERFORMED. <br />13) THAT ANY APPRENTICES EMPLOYED IN THE ABOVE PERIOD ARE DULY REGISTERED IN A BONA FIDE APPRENTICESHIP PROGRAM REGISTERED WITH A STATE APPRENTICESHIP AGENCY <br />RECOGNIZED BY THE BUREAU OF APPRENTICESHIP AND TRAINING, UNITED STATES DEPARTMENT OF LABOR, OR IF NO SUCH RECOGNIZED AGENCY EXISTS IN A STATE, ARE REGISTERED <br />WITH THE BUREAU OFAPPRENTICESHIP AND TRAINING, UNITED STATES DEPARTMENT OF LABOR. <br />I HAVE READ THIS CERTIFIED STATEMENT, KNGW THE CONTENTS THEREOF AND IT IS TRUE TO MY KNOWLEDGE. <br />NAME AND TITLE SIGNATURE <br />NOTE TO CONTRACTORS: YOU MUST ATTACH COPIES OF THIS FORM TO EACH OF YOUR PAYROLL SUBMISSIONS ON THIS PROJECT. SEE THE BOLI PUBIICATION PREVAILING WAGE <br />RATES FOR PUBLIC WORKS GONTRAGTS IN OREGON FOR INSTRUCTIONS ON COMPLETING THIS FORM. • <br />FILE THIS FORM WITH THE CONTRACTING AGENCY <br />