Form Wh 40 – Fill Out and Use This PDF

PUBLIC WORKS FEE ADJUSTMENT FORM

THIS FORM TO BE USED FOR RECONCILIATION OF FEES UPON COMPLETION OF

PUBLIC WORKS PROJECTS

(As required by ORS 279C.825 and OAR 839-025-0210)

PUBLIC AGENCIES: Complete and mail this form to BOLI at the above address after completion of the public work project and not less than 30 days after the final progress payment is made to the contractor. Public agencies are required to determine the final contract price, including all change orders or other adjustments to the original contract price, and to calculate the adjusted prevailing wage rate fee based on the revised contract price. Documentation must be included to support the final contract price. Documentation of the final contract price may consist of change orders or other contract documents substantiating the amount of the contract. The prevailing wage rate fee of one-tenth of one percent (.001) shall be applied to the final contract price, with credit taken for fees already submitted. The public agency must submit any additional fee payable to BOLI, or submit any request for refund, with this adjustment form. NO ADDITIONAL FEE IS REQUIRED TO BE

PAID, AND REFUNDS WILL NOT BE MADE, FOR RECONCILED AMOUNTS OF LESS THAN $100.00.

PUBLIC AGENCY:

AGENCY #:

AGENCY CONTACT PERSON:

PHONE:(

)

MAILING ADDRESS:

PROJECT NAME:

CONTRACT NAME (if part of larger project):

PROJECT NUMBER:

PROJECT LOCATION:

CONTRACTOR/BUSINESS NAME (DBA):

CONTRACTOR CCB#:

DATE AWARDED:

FINAL CONTRACT/PROJECT AMOUNT:

FINAL FEE DUE:

(Include all change orders and adjustments to the contract price)

(Final Contract amount X

.001)

ORIGINAL CONTRACT AMOUNT:

INITIAL FEE PAID:

(Original Contract amount X .001)

TOTAL ADJUSTMENT:

BALANCE DUE*:

or

REFUND DUE*:

*Final contract fee less initial fee paid

Sample Calculation:

Final Contract Amount:

$ 400,000.00

Final Fee Due:

$ 400.00

Original Contract Amount:

- 300,000.00

Initial Fee Paid:

- 300.00

Total Adjustment:

$ 100,000.00

Additional Amount Due:

$ 100.00

(Please duplicate this form for future use)

WH-40 (Rev. 11/07)