
CERTIFIED STATEMENT
Date:
I, ,
(NAME OF SIGNATORY PARTY) (TITLE)
do hereby state:
(1) That I pay or supervise the payment of the persons employed by:
(CONTRACTOR, SUBCONTRACTOR OR SURETY)
on the ; that during the payroll period
(BUILDING OR WORK)
commencing on the day of , , and ending the day
(MONTH) (YEAR)
of , , all persons employed on said project have been paid the
(MONTH) (YEAR)
full weekly wages earned, that no rebates have been or will be made either directly or
indirectly to or on behalf of said
(CONTRACTOR, SUBCONTRACTOR OR SURETY)
from the full weekly wages earned by any person, and that no deductions have been
made either directly or indirectly from the full wages earned by any person, other than
permissible deductions as specified in ORS 652.610, and as defined in Regulations, Part
3 (29 CFR Subtitle A), issued by the Secretary of Labor under the Copeland Act, as
amended (48 Stat. 948, 63 Stat. 108, 72 Stat. 967; 76 Stat. 357; 40 U.S.C. 276c), and
described below:
(2) That any payrolls otherwise under this contract required to be submitted for the above
period are correct and complete; that the wage rates for workers contained therein are
not less than the applicable wage rates contained in any wage determination
incorporated into the contract; that the classifications set forth therein for each worker
conform with work performed.
(3) That any apprentices employed in the above period are duly registered in a bona fide
apprenticeship program registered with a state apprenticeship agency recognized by the
Bureau of Apprenticeship and Training, United States Department of Labor, or if no such
recognized agency exists in a state, are registered with the Bureau of Apprenticeship
and Training, United States Department of Labor.
I HAVE READ THIS CERTIFIED STATEMENT, KNOW THE CONTENTS THEREOF
AND IT IS TRUE TO MY KNOWLEDGE:
(NAME AND TITLE)
(SIGNATURE AND DATE)
In addition to completing sections (1) - (3), if your project is subject to the federal
Davis-Bacon Act requirements, complete the following section as well:
(4) That:
(a) WHERE FRINGE BENEFITS ARE PAID TO APPROVED PLANS, FUNDS OR
PROGRAMS
- In addition to the basic hourly wage rates paid to each laborer or mechanic
listed in the above referenced payroll, payments of fringe benefits as listed in
the contract have been or will be made to appropriate programs for the benefit
of such employees, except as noted in Section 4(c) below.
(b) WHERE FRINGE BENEFITS ARE PAID IN CASH
- Each laborer or mechanic listed in the above referenced payroll has been paid,
as indicated on the payroll, an amount not less than the sum of the applicable
basic hourly wage rate plus the amount of the required fringe benefits as listed
in the contract, except as noted in Section 4(c) below.
(c) EXCEPTIONS:
EXCEPTION (CRAFT) EXPLANATION
REMARKS:
NAME AND TITLE SIGNATURE
THE WILLFUL FALSIFICATION OF ANY OF THE ABOVE STATEMENTS MAY
SUBJECT THE CONTRACTOR OR SUBCONTRACTOR TO CIVIL OR CRIMINAL
PROSECUTION. SEE SECTION 1001 OF TITLE 18 AND SECTION 231 OF TITLE 31
OF THE UNITED STATES CODE.
FILE THIS FORM WITH THE PUBLIC AGENCY ASSOCIATED WITH THE PROJECT
NOTE TO CONTRACTORS: YOU MUST ATTACH COPIES OF THIS FORM TO EACH OF YOUR PAYROLL SUBMISSIONS ON THIS PROJECT.
INSTRUCTIONS AND ADDITIONAL FORMS ARE AVAILABLE ON OUR WEBSITE: WWW.OREGON.GOV/BOLI.
WH-38 (Rev. 05/16)