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BVREAU OF 1A80H AND INOUSTRIES <br />WAGE AND HOUR OIVIS~ON <br />PRIME CONTRACTOR ^ <br />SUBCONTRACTOR ~ <br />FIRST ^ 90 DAY ^ LAST ^ <br />PAYROLLICERTIFIEO STATEMENT FORM WH-38 <br />FOR USE IN COMPLYING WITH ORS 279.354 <br />Business Name (DBA): CCB Registration Number: <br />Phone: Project Name: Project Number: <br />T e Of Work: <br />treet Address: <br />ailing Address: <br />Date Pay Period Began: Date Pay Period Ended: <br />THIS SECTION FOR PRIME CONTRACTORS ONLY <br />Public ConVacting Agency Name: <br />Phone: ( ) <br />Date Conuact Specifications First Advertised For Bid: <br />Contract Amount Project Location: <br />Project County: <br /> <br />THIS SECTION FOR SUBCONTRACTORS ONLY <br />Subcontract Amount: <br />Prime Contractor Business Name (DBA): <br />Phone: ( ) CCB Registration Number. <br />Date You Be an Work On The Pro'ect: <br />(1) (2) (3) DAY AND DATE (4) (5) (6) (7) (8) (9) (10) (11) <br />NAME, ADDRE55 AND TRA~E. TOTAL <br />HOURS BASIC <br />HOURLY HOURLY FRINGE <br />BENEFIT PAID AS GROSS <br />AMOUNT TOTAL <br />DEDUCTION NET wAGE <br />PAID FOR HOURLY FFiINGE <br />gENEFIT PAID T NAME OF BENEFIT PARTY, <br />FUND <br />OR <br />PLAN <br />SOCIAI SECURITV <br />NUMBER OF EMPLOYEE CLASSIFICATION <br />I~NCLUDE GROUP <br />RATE OF <br />PAY WAGE TO <br />EMPLOYEE EARNED FICA, FEO, <br />STATE, ETC WEEK <br />PARTY, PLAN, <br />FUND OR , <br />, <br />PROGRAM <br /> X IF APPLICABLE) HOURS WORKED EACH DAY PROGRAM <br /> OT <br /> <br /> <br /> S <br /> OT <br /> <br /> <br /> S <br /> OT <br /> <br /> <br /> S <br /> <br /> OT <br /> <br /> S <br />THIS FORM CONTINUED ON REVERSE <br />FORM WH-38 (REV. 6/96) <br />