Statement Of Compliance Form – Fill Out and Use This PDF

Enter the CONTRACTOR OR SUBCONTRACTOR, the CONTRACT NUMBER, the CONTRACTORS STATE LICENSE BOARD NUMBER and the DEPARTMENT OF INDUSTRIAL RELATIONS REGISTRATION NUMBER.

Enter the FIRST DAY AND DATE OF PAY PERIOD and the LAST DAY AND DATE OF PAY PERIOD.

A contractor required to pay Federal Wage Rates must check paragraph 2(a) to indicate that the wage rates for laborers or mechanics contained in the payroll are not less than the applicable wage rates specified in the applicable wage determination incorporated into the contract.

A contractor required to pay the State Prevailing Wage Rates as determined by the Director of Industrial Relations must check paragraph 2(b) to indicate that the wage rates for laborers or mechanics contained in the payroll are not less than the applicable wage rates determined by the Director of Industrial Relations for the county or counties in which the work is performed.

A contractor who pays fringe benefits to approved plans, funds, or programs in amounts not less than were determined in the applicable wage decisions must check paragraph 4(a) to indicate that he or she is also paying approved plans, funds, or programs within the times required for the receipt of those sums, not less than the amount predetermined as fringe benefits for each craft. Any exception must be noted in Section 4(c).

(4)(a) Fringe benefits as listed in the contract have been or will be paid to the approved plan(s), fund(s), or program(s) for the benefit of listed employee(s), except as noted in the following table.

(4)(b) Fringe benefits as listed in the contract have been paid directly to the listed employee(s), except as noted in the following table.

A contractor who does not pay fringe benefits to an approved plan must pay a like amount to the employee, and must check paragraph 4(b) to indicate that he or she is paying fringe benefits directly to his or her employees. Any exceptions must be noted in Section 4(c).

Any exceptions to Section 4(a) and 4(b), whichever the contractor may check, must be entered in Section 4(c).

(4)(c) See exceptions noted in the following table.

In Section 4(c), Exceptions: any contractor who is making payment to approved plans, funds, or programs in amounts less than the wage determination required is obligated to pay the deficiency directly to the employees as wages instead of fringes.

Enter in the Exception column the craft, and enter in the Explanation column the hourly amount paid the employees as wages instead of fringes, and the hourly amount paid to plans, funds, or programs as fringes (see United States Code, Title 18, Section 1001 and Title 31, Section 3729).

Print the NAME (PLEASE PRINT) and the TITLE, then SIGN and enter the DATE.

By providing your electronic signature for this form, you agree to conduct business transactions by electronic means and that your electronic signature is the legal binding equivalent to your handwritten signature.

Your electronic signature represents your execution or authentication of this form, and your intent to be bound by it.

The willful falsification of any of the above statements may subject the contractor or subcontractor to civil or criminal prosecution (see United States Code, Title 18, Section 1001 and Title 31, Section 3729).

You certify that all persons employed on said project for the time period referenced on this form have been paid their full weekly wages earned, that no rebates have been or will be made either directly or indirectly to or on behalf of said contractor 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.