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Get Cem 2501 1994-2024

STATE OF CALIFORNIA DEPARTMENT OF TRANSPORTATION FRINGE BENEFIT STATEMENT CEM-2501 REV 8/1994 CONTRACTOR OR SUBCONTRACTOR Please Print CONTRACT NUMBER FEDERAL-AID PROJECT NUMBER DATE ABC Contractors Inc - CT office Proj 2 12-9858965 08/01/2012 TO RESIDENT ENGINEER OR DISTRICT LABOR COMPLIANCE OFFICER BUSINESS ADDRESS California Dept. Of Transportation Sacramento Office 123 Some Street Suite 100 Sometown CA 99999 Labor Compliance uses the following fringe benefits information shown or referenced on wage rate determinations paid to or on behalf of employees in various crafts or classifications to check payrolls or apply to force account work on the above contract. COMPLETE AND SUBMIT THIS FORM WITH THE FIRST CERTIFIED PAYROLL OR WHEN THERE HAVE BEEN CHANGES. Classification Heavy Equipment Operator Effective Date Subsistence and/or Travel Pay Heavy Highway Labor Heavy Highway Pipe Fitter 01/01/2002 Fringe Benefit Hourly Amount Vacation Health and Welfare 10. STATE OF CALIFORNIA DEPARTMENT OF TRANSPORTATION FRINGE BENEFIT STATEMENT CEM-2501 REV 8/1994 CONTRACTOR OR SUBCONTRACTOR Please Print CONTRACT NUMBER FEDERAL-AID PROJECT NUMBER DATE ABC Contractors Inc - CT office Proj 2 12-9858965 08/01/2012 TO RESIDENT ENGINEER OR DISTRICT LABOR COMPLIANCE OFFICER BUSINESS ADDRESS California Dept. Of Transportation Sacramento Office 123 Some Street Suite 100 Sometown CA 99999 Labor Compliance uses the following fringe benefits information shown or referenced on wage rate determinations paid to or on behalf of employees in various crafts or classifications to check payrolls or apply to force account work on the above contract. COMPLETE AND SUBMIT THIS FORM WITH THE FIRST CERTIFIED PAYROLL OR WHEN THERE HAVE BEEN CHANGES* Classification Heavy Equipment Operator Effective Date Subsistence and/or Travel Pay Heavy Highway Labor Heavy Highway Pipe Fitter 01/01/2002 Fringe Benefit Hourly Amount Vacation Health and Welfare 10. 50 Pension Apprentice or Training Fees Other Name and Address of Plan Fund or Program Capitol Blue Cross/BlueShield Group 123321 12 Main Street Town ST ZIP I certify under penalty of perjury that fringe benefits are paid to the approved Plans Funds or Programs listed above. NAME AND TITLE PLEASE PRINT. John Smith President SIGNATURE BUSINESS TELEPHONE NUMBER 555 555-5555 ADA Notice For individuals with sensory disabilities this document is available in alternate formats. For more information call 916 654-6410 or TDD 916 654-3880 or write Records and Forms Management 1120 N street MS-89 Sacramento CA 95814 CEM2501. STATE OF CALIFORNIA DEPARTMENT OF TRANSPORTATION FRINGE BENEFIT STATEMENT CEM-2501 REV 8/1994 CONTRACTOR OR SUBCONTRACTOR Please Print CONTRACT NUMBER FEDERAL-AID PROJECT NUMBER DATE ABC Contractors Inc - CT office Proj 2 12-9858965 08/01/2012 TO RESIDENT ENGINEER OR DISTRICT LABOR COMPLIANCE OFFICER BUSINESS ADDRESS California Dept. Of Transportation Sacramento Office 123 Some Street Suite 100 Sometown CA 99999 Labor Compliance uses the following fringe benefits information shown or referenced on wage rate determinations paid to or on behalf of employees in various crafts or classifications to check payrolls or apply to force account work on the above contract. .

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