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Fringe benefit statement 2026
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- Click ‘Get Form’ to open the fringe benefit statement in the editor.
- Begin by entering the Contract Bid # and W/O# at the top of the form, followed by the Contract Name and Location. This information is crucial for identifying the specific contract related to the benefits.
- Fill in your Contractor/Subcontractor Name, Today’s Date, and Business Address with Telephone number. Accurate contact details ensure proper communication regarding benefits.
- In the 'Fringe Benefits' section, list each classification of work along with its Effective Date and Determination Number. This helps in verifying rates during payroll checks.
- For each classification, input the corresponding amounts for Health & Welfare, Vacation/Holiday, Training and/or Other benefits. Ensure that you specify who these payments are PAID TO by including their Name and Address/Phone.
- If applicable, include Subsistence or Travel Pay amounts under their respective sections. Remember to provide details on who these payments are directed to as well.
- Finally, complete the form by printing your name/title and signing it at the bottom. This confirms that all information provided is accurate.
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Related links
All Departments must complete this form, when a taxable fringe benefit is received by an employee. This form must be completed within 15 days of receivingRead more
Statement of Employer Payments. HEALTH AND WELFARE NAME OF PLAN Address, City and Zip ADMINISTRATOR Address, City and Zip CLASSIFICATION(S) USED CONTRIBUTION