Attachment_J-13_Pay_Application.xls
XLS spreadsheet 109 KB Posted
- Attached to
- Poplar Ancillary Healthcare Facility & Vern E Gibbs Health Center Construction Renovation
- Solicitation number
- 19-102-SOL-00026
About this file
This sources sought notice is seeking capability statements from contractors for the construction of the Poplar Ancillary Healthcare Facility and renovation of the Vern E Gibbs Health Center located on the Fort Peck Reservation in Poplar, Montana. The estimated value of construction is over $10 million. Capability statements are due by March 12, 2019. The resulting contract is expected to be awarded on or about May 24, 2019 as a fixed-price contract. The solicitation documents will be made available on or about April 18, 2019 on FBO.gov. The estimated response due date for proposals is May 17, 2019. The notice includes attachments such as preliminary drawings, specifications, wage determinations, environmental reports, capability and evaluation criteria questionnaires, and information on certified Indian preference firms.
Attachment J-13: Pay Application (4 pages)
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Text version
Payment
| CONTRACT REQUEST FOR PAYMENT | ||||||
| Name and Address of Contractor and DUNS number | Project Title and Location: (Contract No. is above entered.) | |||||
| Gallup Indian Medical Center Emergency Department Renovation And Expansion Project Gallup, NM | ||||||
| To be completed by the Contractor: | To be completed by the Government: | |||||
| 1. | Original Contract Amount (Part A Column E) | $ - 0 | (Enter amount from item 10) | $ - 0 | ||
| 2. | Net Change by Modifications (Part B Column F) | $ - 0 | ||||
| 3. | Adjusted Contract Amount to Date (1 + 2) | $ - 0 | 11. | Amount retained by Government per contract | $ - 0 | |
| 4. | Original Contract Work Complete (Part A Column J) | $ - 0 | FAR 52.232-5(e)...explanation of amount withheld: | |||
| 5. | Modification Work Complete (Part B Column J) | $ - 0 | ||||
| $ - 0 | ||||||
| 6. | Total Progress (4 + 5) | $ - 0 | ||||
| 7. | Subcontract Retention (Part C Column G) | $ - 0 | ||||
| 8. | Net Earned Progress (6 - 7) | $ - 0 | 12. | Balance Due This Pay Request (10 - 11) | $ - 0 | |
| 9. | Previous Payments | $ - 0 | ||||
| 10. | Net Payment Requested (8 - 9) | $ - 0 | Government Project Officer Certification: | |||
| I certify that all work and/or materials under the contract have been inspected by the Government and that the work and/or materials have been performed and/or supplied in full accordance with the requirements of the contract. I recommend that the Contractor should be paid the amount requested and/or adjusted amount noted on this form. | ||||||
| Contractor Certification Per FAR 52.232-5 (c) | ||||||
| Per FAR 52.232-5(c) the Contractor shall furnish the following certification, or payment shall not be made: |
(However, if the Contractor elects to delete paragraph (c)(4) from thecertification, the certification is still acceptable.)
| I hereby certify, to the best of my knowledge and belief, that-- | Government Project Officer | Date Proper Invoice Received | |||
| (1) The amounts requested are only for performance in accordance with the specifications, terms, and conditions of the contract; | Funds Certification: | ||||
| (2) Payments to subcontractors and suppliers have been made from previous payments received under the contract, and timely payments will be made from the proceeds of the payment covered by this certification, in accordance with subcontract agreements and the requirements of Chapter 39 of Title 31, United States Code; | |||||
| Financial Project Management Technician | Date | ||||
| Approved By: | |||||
| (3) This request for progress payments does not include any amounts which the prime contractor intends to withhold or retain from a subcontractor or supplier in accordance with the terms and conditions of the subcontract; and | |||||
| (4) This certification is not to be construed as final acceptance of a subcontractor's performance. | Division of Facilities Engineering | Date | |||
| Signature/title | Date | Contracting Officer Signature | Date | ||
| Prompt Payment Provisions Effective: _______________________ |
&CAttachment J-13 Pay Application cwolf:
Enter contract number.
Indian Health Service
DEPARTMENT OF HEALTH & HUMAN SERVICES
Pay Request Part A (orig)
| Periodic Estimate for Progress Payment No.: | |||||||||||
| Name of Contractor | Contract Number | ||||||||||
| PART - A: Completed Work Under Original Contract | |||||||||||
| A | B | C | D | E | F | G | H | I | J | ||
| Item No. | Description of Item | Qty | Unit of Issue | Unit Price | Total Price | Percentage or Estimated Amounts Installed | Payments | Total Complete | |||
| Previous | This Period | Previous | This Period | ||||||||
| 1 | $ - 0 | 0.00% | 0.00% | $ - 0 | BASIC SERVICES | ||||||
| 2 | $ - 0 | 0.00% | $ - 0 | $ - 0 | $ - 0 | ||||||
| 3 | $ - 0 | 0.00% | $ - 0 | $ - 0 | $ - 0 | ||||||
| 4 | $ - 0 | 0.00% | $ - 0 | $ - 0 | $ - 0 | ||||||
| 5 | $ - 0 | 0.00% | $ - 0 | $ - 0 | $ - 0 | ||||||
| 6 | $ - 0 | 0.00% | $ - 0 | $ - 0 | $ - 0 | ||||||
| 7 | $ - 0 | 0.00% | $ - 0 | $ - 0 | $ - 0 | ||||||
| 8 | $ - 0 | 0.00% | $ - 0 | $ - 0 | $ - 0 | ||||||
| 9 | $ - 0 | 0.00% | $ - 0 | $ - 0 | $ - 0 | ||||||
| 10 | $ - 0 | 0.00% | $ - 0 | $ - 0 | $ - 0 | ||||||
| 11 | $ - 0 | 0.00% | $ - 0 | $ - 0 | $ - 0 | ||||||
| Totals | $ - 0 | 0% | 0.00% | $ - 0 | $ - 0 | $ - 0 | |||||
| Contractor: _______________________________________________________ | ____________________ | ||||||||||
| Signature/Title | Date | ||||||||||
| Government Approval: ______________________________________________ | ____________________ | ||||||||||
| Project Officer | Date | ||||||||||
| ______________________________________________ | ____________________ | ||||||||||
| Contracting Officer | Date |
cwolf:
Enter contract number.
cwolf:
Enter contract number.
cwolf:
Enter contract number.
Indian Health Service
DEPARTMENT OF HEALTH & HUMAN SERVICES
Pay Request Part B(mods)
| Periodic Estimate for Progress Payment No.: | ||||||||||
| Name of Contractor | Contract Number | |||||||||
| PART - B: Contract Modifications | ||||||||||
| A | B | C | D | E | F | G | H | I | J | |
| Mod # | Line Item # | Description of Item | Qty | Unit of Issue | Unit Cost | Total Cost | Completed | Stored Materials | Total Completed & Stored | |
| Previous | This Period | |||||||||
| $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||||||
| $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||||||
| $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||||||
| $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||||||
| $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||||||
| $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||||||
| $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||||||
| $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||||||
| $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||||||
| $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||||||
| $ - 0 | $ - 0 | $ - 0 | ||||||||
| $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||||||
| $ - 0 | $ - 0 | |||||||||
| $ - 0 | $ - 0 | |||||||||
| $ - 0 | $ - 0 | |||||||||
| $ - 0 | $ - 0 | |||||||||
| $ - 0 | $ - 0 | |||||||||
| $ - 0 | ||||||||||
| $ - 0 | $ - 0 | |||||||||
| $ - 0 | ||||||||||
| $ - 0 | ||||||||||
| $ - 0 | ||||||||||
| $ - 0 | ||||||||||
| $ - 0 | ||||||||||
| $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||||||
| Totals | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
cwolf:
Enter contract number.
Indian Health Service
DEPARTMENT OF HEALTH & HUMAN SERVICES
Pay Request Part C (subs)
| Periodic Estimate for Progress Payment No. : | |||||||
| Name of Contractor | Contract Number | ||||||
| PART - C: Payments to Subcontractors | |||||||
| A | B | C | D | E | F | G | H |
| Line Item No. | Subcontractor Name | Subcontract Amount Including Changes | Progress | Retention in Accordance with Subcontract Terms | Net Due to Subcontractor Through This Application for Payment | ||
| Previous | This Period | Total | |||||
| 1 | $ - 0 | $ - 0 | $ - 0 | ||||
| 2 | $ - 0 | $ - 0 | $ - 0 | ||||
| 3 | $ - 0 | $ - 0 | $ - 0 | ||||
| 4 | $ - 0 | $ - 0 | $ - 0 | ||||
| 5 | $ - 0 | $ - 0 | $ - 0 | ||||
| 6 | $ - 0 | $ - 0 | |||||
| 7 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||
| 8 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||
| 9 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||
| 10 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||
| 11 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |
| 12 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |
| 13 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |
| 14 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |
| 15 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |
| 16 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |
| 17 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |
| 18 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |
| 19 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |
| 20 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |
| 21 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |
| Totals | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 |
cwolf:
Enter contract number.
Indian Health Service
DEPARTMENT OF HEALTH & HUMAN SERVICES
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