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lsui~~.~au oi Labor and Indust i~i~,s
<br />1?1~eva_il ing Wage Rat.e Un i t
<br />~300 N. E. Oregon St ., #} 3:'
<br />Portland, OR 97?_32.
<br />~~hc~nr~: (503) 731-40"19, ext._ :'S0
<br />}~AX: (503) 737-4613 ~
<br />~.'SIB~z~ W4R$~ _~4__~RA~T __~'~E__~s~L~aTME13T-F_QRM
<br />THIS FORM TO BE CJSED FOR RECONCILIATION OF FFES ON COMPLETION OF'
<br />PUBLIC WORKS PROJECTS
<br />tA:~. r~~r~uii~r~d t~y OR`~; 279.375 an<j 1~A1: Ri~+ Ih 270)
<br />t:~,~!11L4~4'C41~:~' }'lr•asc~ c~~mf;l~r±~• and m,ail this f~~r~m f~~ f~CiI,I ~it the~ at,~-~v~ ~a~l~3i~r:;., aft~~i
<br />r~~mE~J r•t i<>n c~f t h~• E,nt>1 i~~ w~,i~kt, ~;rc> ~r,ct ~anu nr~t I r°:;:; t Yi~~n 30 da;~s ~~I t~~~ t lir t i n~i l
<br />jiayment l~y ~ he~ ~~c>nt r,i~ t i uy .iyr~ur_y . C<~nL~ ,3c~tr~i s<3r c i c~•~~u i r ed t~~> det erminr~~ t ht~ f i n~, l
<br />cont.i~act price, inclu~liny a11 r~hanye ordei~s oi~ c~th~~r ~acijusCmrri~its ~c~ t_hr~ ~_,~~ic~in~il
<br />cont ract pt ic<~~ and t o ~ r~ 1 cii] at.~ Y he~ ac~ ji_isLed pr~~va i 1 i r~iy w,aye~ rat c~ f ee, bat~:~~<j ~~n f I~~r~
<br />revi ~ed c~c~nt_r~act_ pricc~ I)~~<~~~meiitation musC h~ include~~~ t~~, support: thF~ f inal <~nr~t r.~~ t
<br />pzice. The prc:vailin~'~ waqe rate fee, 001, (i/1Ot1~ c~f 1%) ;Y~all tie applie~3 1<~ th~1
<br />f ina 1 cont.ract pri cr,, wi t h cr~edi.t Laken for f~~e:~ a 1 re~a~~y ;>ubmi t ted . 'I'he~ r~~>nt~ t~,,<~t r~r
<br />must subm~ t t~h~~, add i t i~>i~a 1 f ee payabl r~ tc~ AOL] wi t h t h~~ a<i justment f~~rm or ~ c~~~u~•:;t_s
<br />fr~t refund i f appl i cat,~1 c~ ~~~,DDIT~ONAL __F'EE wzLL BE C~ARGED,__~QR_ A
<br />~~'~?_~D~~ 4~--ANY_-~E.~QI~~LED_ AMQ~T~_ N~DER---~ 10 0. 0 0 Z--
<br />BUSINESS NAME (DBA) _ ___ __. _ _. _.__ _ _CCB # _ _ _ _ _
<br />MAILING ADDRESS: _ _. --- __.._ --.--- -_____ _ PHONE: ~__ 1 ____ __
<br />(STREET OR PO BOX #, CITY, STATE, ZIP}
<br />PF20JECT NAME :
<br />PROJECT NUMBER: PROJECT LOCATION:
<br />AGENCY AWARDING CONTRACT: DATE AWARDED:
<br />FINAL CONTRACT AMOUNT: FINAL FEE DUE*:
<br />(ln~~lnde all c-h~3nqe r;r<jc~~i:; ai~r1 adjustments *(I~'~rl~~l i'~,ntr_ac~t amr>unt X.U(i])
<br />t~~ t-he ~-on~ra<~t_ pric~r~;
<br />ORIGINAL CONTRACT AMOUNT: INITIAL FEE PAID*:
<br />_ ____
<br />~ _ -_ " (('~~nt i,,~~t amuunt X .0~1 )
<br />BALANCE DUE: REFiJND DUE:
<br />il~~~naf r~~>>itract f~•e lF~ss n~itial f~~~~ paid)
<br />SamE,l~, Cal<•ulat ic~n:
<br />[~inal C'~~nl rae~t Amuu~~t~ . ;,4(70,000,00 Fina1 I're~• Uiir•: $40~) 00
<br />Ur~y~nal Coi~trar-t Amt _ ~Q4.~J4_9,_94 [nir~at I~~~r~ F'aid: ,344.94
<br />7'nt.al Ar3ju;;lmc~nl : ;;100,0~0.0(1 Amc~ui~~t I)~iF- ~~r~ Refur~~l i)uc-•. ~lOQ.O(~
<br />~I~u,~~iimr•~~~ ~xt~ ii~n in~ty ~~i~,ii;.;:u uf ~~I~~ai~~y<~ ~>> <jr~r~s ~~r r,t hF-~ ~~~~n! i~~~ ~~ dc~cume~,nt °:; t',tit~;>t ;ant iat i n~7
<br />t hr am<,uiit c,f t he• ~•<,ui ~,~< i
<br />i~/iilvs AnJese.s~ (Yleaae duplicate thie form for future uae)
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