INSTRUCTIONS FOR COMPLETING FRINGE BENEFIT STATEMENT (Sample Attached)

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					                       INSTRUCTIONS FOR COMPLETING
                         FRINGE BENEFIT STATEMENT
                               (Sample Attached)


This form must be included with the first certified payroll report if fringe benefits are not
paid in cash to each employee. The form must be signed by a responsible representative of
the company and must be the original signature.

Contract Number: School District
Contract Location: Site of the Project
Contractor/Business Address: Physical address of business, not P.O. Box

All of the following are from the Department of Industrial Relations Website by
Craft:

       Classification: All crafts of employees that you have working on the Project.

       Effective Date: The date of the wage determination for fringe benefits by craft.

       Subsistence or Travel Pay: The amount shown in the wage decision of the craft of
       workers that require subsistence or travel at the Project location.

       Fringe Benefits: The amount of fringe benefits that are paid by craft. If any monies
       are paid on behalf of the employees they must be authorized in writing. All methods
       of payment must be shown on the form.

       Paid To: Insert the name and address of the Plan where the monies are being paid.
       (Do not list the employees’ names, only where the monies are going)

Note: If you do not make your fringe benefit payments to the local union trust fund you
may still claim your own benefit program paid on behalf of your employees, as long as the
amounts do not exceed the total amount shown on the Department of Industrial Relations
Wage Decision that is posted on their website. If the difference in the amount of your
program is less than the amount shown in the wage determination then the difference must
be paid to the employee as part as the basic wage rate. Remember that any Pension Fund
payments must be irrevocably paid to a “Third Party Trust”.
                                                      KEENAN & ASSOCIATES
                                    CONTRACTOR FRINGE BENEFIT STATEMENT
    Contract Number / Name:              Contract Location:                                                Today's Date:


Contractor / Subcontractor Name:                                            Business Address:


In order that the proper Fringe Benefit rates can be verified when checking payrolls on the above contract, the hourly
rates for fringe benefits, subsistence and/or travel allowance payment made for employees on the various classes of
work are tabulated below.

Classification:                                   Effective Date:                               Subsistence or Travel Pay:
                                                                                                       $
                      Health &       $              PAID TO:     Name:
                       Welfare                                 Address:
 FRINGE BENEFITS




                       Pension       $              PAID TO:     Name:
                                                               Address:
                      Vacation/      $              PAID TO:        Name:
                        Holiday                                Address:
                       Training      $              PAID TO:     Name:
                   and/or Other                                Address:

Classification:                                   Effective Date:                               Subsistence or Travel Pay:
                                                                                                       $
                      Health &       $              PAID TO:     Name:
                       Welfare                                 Address:
 FRINGE BENEFITS




                       Pension       $              PAID TO:     Name:
                                                               Address:
                      Vacation/      $              PAID TO:        Name:
                        Holiday                                Address:
                       Training      $              PAID TO:     Name:
                   And/or Other                                Address:

Classification:                                   Effective Date:                               Subsistence or Travel Pay:
                                                                                                       $
                      Health &       $              PAID TO:     Name:
                       Welfare                                 Address:
 FRINGE BENEFITS




                       Pension       $              PAID TO:     Name:
                                                               Address:
                      Vacation/      $              PAID TO:        Name:
                        Holiday                                Address:
                       Training      $              PAID TO:     Name:
                   And/or Other                                Address:


 Supplemental statements must be submitted during the progress of work should a change in rate of any of the classifications be made.

Submitted:             Contractor / Subcontractor                                     By:       Name / Title

				
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