Statement Of Employer Payments Form

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Statement of Employer Payments
Date:
In Reply, Refer to Case No:
Prime:
Subcontractor:
PROJECT NAME:
PROJECT CONTRACT NO.:
County/location:
HEALTH AND WELFARE
NAME OF PLAN
Address, City and Zip
ADMINISTRATOR
Address, City and Zip
CLASSIFICATION(S) USED
CONTRIBUTION PER CLASSIFICATION PER HOUR
CONTRIBUTIONS:
WEEKLY_____
MONTHLY_____
QUARTERLY_____
ANNUALLY_____
PENSION
NAME OF PLAN
Address, City and Zip
ADMINISTRATOR
Address, City and Zip
CLASSIFICATION(S) USED
CONTRIBUTION PER CLASSIFICATION PER HOUR
CONTRIBUTIONS:
WEEKLY_____
MONTHLY_____
QUARTERLY_____
ANNUALLY_____
VACATION/HOLIDAY
NAME OF PLAN
Address, City and Zip
ADMINISTRATOR
Address, City and Zip
CLASSIFICATION(S) USED
CONTRIBUTION PER CLASSIFICATION PER HOUR
CONTRIBUTIONS:
WEEKLY_____
MONTHLY_____
QUARTERLY_____
ANNUALLY_____
TRAINING
NAME OF PLAN
Address, City and Zip
ADMINISTRATOR
Address, City and Zip
CLASSIFICATION(S) USED
CONTRIBUTION PER CLASSIFICATION PER HOUR
CONTRIBUTIONS:
WEEKLY_____
MONTHLY_____
QUARTERLY_____
ANNUALLY_____
IF YOU USE OTHER PLANS NOT LISTED ABOVE, YOU MAY USE THE BACK OF THIS FORM TO PROVIDE
THIS ADDITIONAL INFORMATION
PW 26

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