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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 />THIS FORM TO BE IISED FOR RECONCILIATION OF FEES ON COMPLETION OF <br />PIIBLIC WORKS PROJECTS <br />(As required by ORS 279.375 and OAR 839-16-210) <br />c'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 it) 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. ±:O ADDITIONAL FEE WILL B~ ~'~ARC:F.1) NOR A <br />RFFTTt~^~ ~A~E ON ANY ~~'~'n*rrTr Fn AM~UNTS TT~FR ~~ ~0 . 00 ._ <br />BIISINESS NAM$ (DBA) CCB # <br />MAILING l1DDRSSS: PHONS: <br />(STREST OR PO BO% #. CITY, STATE, ZIP) <br />PROJECT NAMS: <br />PROJfiCT NUMBFsR: PROJECT LOCATION: <br />AGSNCY AWARDING CONTRACT: <br />FINAL CONTRACT AMOIINT: <br />(Include all change orders and adjustments <br />to the contract price) <br />ORIGINAL CONTRACT AMOIINT: <br />BALANCE DIIE: <br />Sample Calculation: <br />FINAL F$S DU$*: <br />*(Final Contract amount X .001) <br />INITIAL FSE PAID*: <br />+(Contract amount X .001) <br />REFUND DIIE: <br />(Final contract fee less initial fee paid) <br />Final Contract Amount: $400,000.00 Final Fee Due: $400.00 <br />Original Contract Amt: -"~00.000.00 Initial Fee Paid: -~00.00 <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 />the amount of the contract. <br />DATg AWARDSD: <br />lz/11/~5 ~n.m~•u~ (Pleaee duplicate this form for future use) <br />