Fillable OAK023271 (City of Oakland)

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OAK023271 (City of Oakland)

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City of Oakland Local Employment Program Fringe Benefits Statement
PROJECT NAME: PROJECT #:
COMPANY NAME:
A
DDRESS:
CONTACT PERSON: TELEPHONE #:
Classification
Fringe Benefits
Hourly Amount Name & Address of Plan, Fund or
Program
Health &
Welfare
Pension
Vacation
Apprentice/
Training
Other
Classification
Fringe Benefits
Hourly Amount Name & Address of Plan, Fund or
Program
Health &
Welfare
Pension
Vacation
Apprentice/
Training
Other
Classification
Fringe Benefits
Hourly Amount Name & Address of Plan, Fund or
Program
Welfare
Pension
Vacation
Apprentice/
Training
Other
I certify under penalty of perjury that fringe benefits are paid to the approved Plans, Funds or Programs as
listed above.
Name & Title (Print) Signature Date
*This form can be fax to LEP at 510-238-3363 or email as an attachment to cces@oaklandnet.com
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OAK023271 (City of Oakland)

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Completed 18 July 2020

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