California fringe benefit statement: Fill out & sign online

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Click ‘Get Form’ to open the Contractors FB form in the editor.
Begin by entering the Contract Number/Name and Contract Location at the top of the form. This information is essential for identifying the specific contract.
Fill in Today's Date, followed by the Contractor/Subcontractor Name and Business Address. Accurate details here ensure proper communication.
In the Fringe Benefits section, list each classification along with its Effective Date. Enter the corresponding amounts for Health & Welfare, Pension, Vacation/Holiday, and any Training or Other benefits.
For each benefit type, specify who it is paid to by filling in their Name and Address. This ensures transparency in benefit distribution.
If applicable, include Subsistence or Travel Pay details in the designated fields, ensuring all relevant payments are documented.
Finally, submit the form by signing it with your Name/Title as Contractor/Subcontractor. Ensure all changes in rates are documented through supplemental statements during work progress.

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