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Contractor fringe benefit statement fillable pdf 2026

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The document is a Contractor Fringe Benefit Statement that outlines the hourly rates for various fringe benefits, including health and welfare, pension, vacation/holiday, and training for employees involved in a specific project. It includes sections for contractor and subcontractor information, effective dates, and payment details. The statement emphasizes the need for supplemental statements if there are changes in benefit rates during the project's progress.

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Click ‘Get Form’ to open the contractor fringe benefit statement fillable PDF in the editor.
Begin by entering the Project Name and Project Number at the top of the form. This information is crucial for identifying the specific contract.
Fill in the County/Location and Date fields to provide context for your submission.
Input details for both the Prime Contractor and Subcontractor, including their respective addresses.
In the FRINGE BENEFITS section, list hourly rates for various classifications such as Health & Welfare, Pension, Vacation/Holiday, and Training. Ensure you specify who each payment is made to.
If applicable, include Subsistence or Travel Pay amounts in the designated fields.
Finally, sign off on the document by entering your name and title under 'Submitted: Contractor / Subcontractor'.

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