Form Affidavit

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					                                    City of Seattle Office of Housing
                                                                                               Page 1 of 2
                                         Affidavit of Wages Paid




 PROJECT INFORMATION
                      Project Name
                    Project Address
           General Contractor Name

 COMPANY INFORMATION
                    Company Name
      WA State Contractors License #
          State UBI # or Federal EIN
                 Company Address
                      City, State, Zip
                      Contact Name
                     Phone Number

 Was all work for your company performed by owner operators?                        Yes        No
    If so, skip to signature block and file this form.
 Did you use any lower tier subcontractors to perform any work on site?             Yes        No
    If so, list please list the lower tier subcontractors below.
                             Company Name
                             Company Name
                             Company Name
                             Company Name

 EMPLOYEE WAGES - Journey level trades
                                            BASE                        TOTAL       Number          Number
                                                        FRINGE
              TRADE or CRAFT                WAGE                        WAGE          of              of
                                                         00.00
                                            00.00                        00.00      Workers          Hours




Revised April 30, 2007                                                      City of Seattle - Office of Housing
                                          City of Seattle Office of Housing
                                                                                                        Page 2 of 2
                                               Affidavit of Wages Paid




 PROJECT INFORMATION
                    Project Name
 COMPANY INFORMATION
                  Company Name

 EMPLOYEE WAGES - Apprentice Trades
                                                                                                    BASE
        Apprentice Name             Apprentice             Apprentice            Apprentice                  FRINGE
                                                                                                    WAGE
    (last name, first name, mi)      Reg. No.               Program                Level                      00.00
                                                                                                    00.00




                                                      AFFIDAVIT

            I declare under penalty of perjury under the laws of the State of Washington that
            (1) all information provided in this form is true and correct, (2) the undersigned is
            an owner or corporate officer of the company named below,

            and is authorized to execute this form, and (3) that all workers employed on this Seattle
            Office of Housing project by this company were paid no less than the applicable
            Prevailing Wage Rate(s) as published by the Washington State Department of Labor
            and Industries.

                   Signature

              Printed Name

                         Title

                         Date




                                                 INSTRUCTIONS

    To be completed by each contractor and subcontractor and returned to the General Contractor.

    The General Contractor and Owner are responsible for forwarding all signed original Affidavits of
    Wages Paid forms to the City of Seattle Office of Housing.




Revised April 30, 2007                                                               City of Seattle - Office of Housing

				
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