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B~reau 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 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 />Contractors: Please compl.ete 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. I)ocumentation 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, wit.h credit taken for fees already submitted. The contractor <br />must submit the additiona:~ fee payable to BOLI with the adjustment form or requests <br />for refund if applicable. NO ADDITIONAL FEE WILL BE CHARGED, NOR A <br />REFUND MADE, ON ANY RECONCILED AMOUNTS UNDER 5100.00. <br />BUSINESS NAMS (DBA) _ CCB # <br />MAILING ADDRESS: PHONE: ( ) <br />(STRF3ET OR PO BO% #, CITY, STATE, ZIP) <br />PROJECT NAME: <br />PROJECT NIItdBER: PROJECT LOCATION: <br />AGENCY AWARDING CONTRACT: DATE AWARDED: <br />FINAL CONTRACT AMOUNT: <br />(Include all change order:; and adjustments <br />to the contract price) <br />ORIGINAL CONTRACT AMOUNT: <br />BALANCE DUE: <br />Sample Calculation: <br />FINAL F$E DIIE*: <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 />the amount of the contract. <br />iz/ii/ss ADJPHH.SIUI (Pleaee duplicate thie form for future uae) <br />