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If any worker is being paid as an apprentice during the period, box 4 must be checked and each program name in which <br />the contractor has registered apprentices working on the project during this payroll period must be listed, with the <br />appropriate box checked to indicate whether the apprenticeship program is registered with DOL’s Office of Apprenticeship <br />(OA) or a State Apprenticeship Agency (SAA), and the name of the labor classification entered. If more than three entries <br />are required, please submit an addendum providing the requested information with the submission of the certified payroll. <br />If box 4 is not applicable, do not check the box and enter “Not Applicable” or “N/A” in the entry subsection, under <br />Apprenticeship Program Name. <br />If the contractor or subcontractor is claiming an hourly credit for their contributions to or reasonably anticipated costs of <br />bona fide fringe benefit plans, funds, or programs, box 5 must be checked and the subsections titled “Hourly Credit for <br />Fringe Benefits” must be completed. In the first column, list each worker entry number (entered in column 1A on the first <br />page) and name of worker for whom the contractor or subcontractor claimed an hourly fringe benefit credit (this should <br />mirror the worker names and order found on Page 1 of the certified payroll form). In the following columns, list each fringe <br />benefit plan name in the top row, fringe benefit plan type in the second row, fringe benefit plan number in the third row, <br />mark whether the fringe benefit plan is funded or unfunded in the fourth row, and state the hourly amount of credit <br />claimed for each worker under each applicable plan in the rows below. In the last column, list the total hourly cost of <br />fringe benefit provided for each worker. Where the contractor or subcontractor is claiming a credit for the reasonably <br />anticipated costs of fringe benefits provided directly by the contractor (commonly referred to as an “unfunded plan”), the <br />contractor or subcontractor must have prior approval from the Depar tment of Labor prior to claiming such credit as <br />required in 29 CFR 5.28. If more than six bona fide fringe benefits are provided to the workers for which the contractor is <br />claiming a credit, submit an addendum for each providing the information requested in this section. <br />Note: If the contractor or subcontractor is meeting its fringe benefit obligations partially through contributions to or <br />reasonably anticipated costs of a bona fide fringe benefit plan and partially through the payment of cash in lieu of fringe <br />benefits, the contractor or subcontractor should enter the respective amounts in this section and in column 6C (Cash <br />Payment in Lieu of Fringe Benefits) on page 1. If the contractor or subcontractor is meeting its fringe benefits obligations by <br />simply paying the cash equivalent to each worker, check the box but do not complete the subsection, because those <br />payments will be reported under column 6C (Cash Payment in Lieu of Fringe Benefits) on page 1. <br />Docusign Envelope ID: CF064D56-F89A-8651-8229-D168AFF8B909