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The following exercise relates to the review of certified payroll records. You can fill it out online, download it and print it for your records.Must accurately reflect. List hourly wage rate and fringes paid in cash. Prevailing wage determinations must be separately listed. The Fringe Benefit Statement lists the employer contributions made on behalf of each employee. Prevailing wage means the basic hourly rate of pay, and the bona fide fringe benefit rate. 2. Fringe Benefit Statement This form shall be submitted with the first certified payroll detailing the fringe benefit contributions. Ii) Some Prevailing Wage Coordinators may require a copy of the completed Notification to the. Fringe Benefit Statement This form shall be submitted with the first certified payroll detailing the fringe benefit contributions.