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Bureau of Labor and Industries <br />Prevailing Wage Rate Unit <br />800 N.E. Oregon St., # 32 <br />Portland, OR 97232 <br />phone: (503) 731-4074, ext. 250 <br />FAX: (503) 731-4623 <br />PUBLIC WORKS CONTRACT FEE ADJUSTMENT FORM <br />THIS FORM TO BE USED FOR RECONCILIATION OF FEES ON COMPLETION OF <br />PUBLIC WORKS PROJECTS <br />(As required by ORS 279.375 and OAR 839-16-210) <br />~ontractors: Please complete and mail this form to BOLI at the above address, after <br />completion of the public works project and not less than 30 days after the final <br />payment by the contracting agency. Contractors are required to determine the final <br />contract price, including all change orders or other adjustments to the original <br />contract price and to calculate the adjusted prevailing wage rate fee, based on the <br />revised contract price. Documentation must be included to support the final contract <br />price. The prevailing wage rate fee, .001, (1/lOth of 1~) shall be applied to the <br />final contract price, with credit taken for fees already submitted. The contractor <br />must submit the additional~fee payable to BOLI with the adjustment form or requests <br />for refund if applicable. ±:Q ADDITIONAL FEE WILL BE CHARGED, NOR A <br />I o~~rn.m ~DE ON ANY RECONCILED AMOUNTS UNDER 5100 00. <br />II <br />I BUSINESS NAME (DBA) CCB # <br />' PHONE: ( ) <br />~ MAILING ADDRESS: <br />~ (STREST OR PO BOX #, CITY, STATE, ZIP) <br />~ PROJRCT NAME: <br />~ PROJECT NUMBfiR: PROJECT LOCATION: <br />AGENCY AWARDING CONTRACT: <br />FINAL CONTRACT AMOUNT: <br />(Include all change orders and adjustments <br />to the contract price) <br />ORIGINAL CONTRACT AMOUNT: <br />BALANCE DUE: <br />Sample Calculation: <br />TE AWARDED: <br />FINAL FEE DUE*: <br />*(Final Contract amount X .001) <br />INITIAL FEE PAID*: _ <br />*(Contract amount X .001) <br />REFUND DUE: <br />(Final contract fee less initial fee paid) <br />Final Contract Amount: $400,000.00 Final Fee Due: $400.00 <br />Original Contract Amt: -300,000.00 Initial Fee Paid: -300.00 <br />Total Adjustment: $100,000.00 Amount Due or Refund Due: $100.00 <br />*Documentation may consist of change orders or other contract documents substantiating <br />rhe amount of the contract. <br />iz/ii/ss anaras.sAx (Please duplicate this form for future uee) <br />