241129-3 ADOT Invoice for Submittal.pdf

Vendor ADOT PM Name

Invoice Status {Select from List}

Partial - In Progress

Invoice Date 11/29/2024

12 1 (619752-8)

8,700.00$ -$ 8,700.00$ -$ 8,700.00$ -$ -$ 0.00% -$ $ - $ 8,700.00

11 2 (619752-7)

39,504.00$ -$ 39,504.00$ 39,504.00$ -$ -$ 0.00% -$ $ - $ -

8 3 (619752-6)

56,256.00$ -$ 56,256.00$ 56,256.00$ -$ -$ 0.00% -$ $ - $ -

6 4 (619752-5)

20,328.00$ -$ 20,328.00$ 20,328.00$ 20,328.00$ 0.00% -$ $ 20,328.00 $ -

5 5 (619752-4)

16,744.00$ -$ 16,744.00$ -$ 16,744.00$ 16,744.00$ 0.00% -$ $ 16,744.00 $ -

4 6 (619752-3)

67,048.00$ -$ 67,048.00$ 67,048.00$ -$ -$ 0.00% -$ $ - $ -

3 7 (619752-2)

658,583.61$ -$ 658,583.61$ 658,583.61$ -$ -$ 0.00% -$ $ - $ -

2 8 (619752-1)

62,792.00$ -$ 62,792.00$ 62,792.00$ -$ -$ 0.00% -$ $ - $ -

-$ -$ -$ -$ 0.00% -$ $ - $ -

929,955.61$ -$ 929,955.61$ 884,183.61$ 45,772.00$ 37,072.00$ -$ -$ 37,072.00$ 8,700.00$

Please Leave Blank

Pavement Data Collection Not to Exceed $648,850.85

Pavement Data-Image Log-GPS Delivery- Not to Exceed $67,048.00

HPMS Delivery- Not to Exceed $16,744.00 dTims PMS Delivery - Not to Exceed $20,328.00

Data QA/QC and Accuracy Verification - Not to Exceed $56, 256.00

Client Meetings- Not to Exceed- $39,504.00

Please Leave Blank

Submitter Certification required pursuant to 2 CFR 200.415: By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and 3801-3812).

Please Leave Blank Please Leave Blank

Project Set Up - Not to Exceed $62792.00

Approved Changes (Cardinal Changes

Prohibited) Travel- Not to Exceed $8700.00

Click Button to Insert Line TOTALS

This section is only applicable to the FINAL reimbursement request submission - Please leave blank.

The fields completed on this page indicate this is the Final Invoice Reimbursement Request and that there was NO Race Conscious Goal On this Project.

Please Leave Blank

Please Leave Blank

Agency PM Name / Email (Notify if Unaccepted / Rejected / Paid)

Michael Nieminen / financeadmin@icc-ims.com Purchase Order Number PO0000663201

241129-3 Project Title

(For Research Project add SPR Number) Geospatial Data Collection

Funding Program {Select from List}

FHWA - All Programs

Invoice Number

Vendor Comment (Optional) Billing Period 11/1/24 to 11/30/24

Federal Funding Agency {Select from List}

FHWA

Remit Payment to {Select from List}

ACH (Direct Deposit)

Master Procurement Contract Number CTR059565

Arizona Department of Transportation Multimodal Planning Division Billing Summary / Reimbursement Request

Subrecipient or Vendor?

{Select from List}

Robert Bush

MPD Tracking Number {Use Format: MPDnnnn-yy; RTAP use " MPDRTAP-yy"} {yy = last 2 digits of the State Fiscal Year (July 1 - June

30)}

MPD0117-21

Agency Name International Cybernetics Corp

Please Leave Blank

Selecting this option, confirms ACH is active on your State Vendor Profile. Leave Blank.

Race Conscious DBE Commitment % {Vendors who are AZ Certified DBEs, enter 100}

Balance (Total Budget -

Previously Invoiced)

Billing for This Invoice

Prior to Reductions

Other Reductions

(e.g. Fares, BECO Sanctions, Disallowed)

Retainage % to Apply to this Invoice

Retainage $ Applied to this

Line

Net Amount Due for

This Invoice

SUMMARY OF WORK FOR WHICH PAYMENT IS REQUESTED

Project Task No

PO Line No

Please Leave Blank

Please Leave Blank

Task or Deliverable Description Balance After This Invoice

Total Awarded Budget

$ (Net Amount) Invoiced

Previously

Originally Awarded Budget Amount

Docusign Envelope ID: 999110B5-379C-4304-ABAB-E764540332B0

REC #1573068

12/03/2024Enter Date Received by MPD and Receipt Number

Date Signed

Please Leave Blank

Date

Color Key

Pink with Red Text = Entry/Correction Required

Progress toward Scope aligns with Awarded Requirements Invoice Approved

Invoice Rejected

Confirmed: BECO required DBE Forms are attached.

12/3/2024

I Confirm No Race Conscious DBE Goal was Assessed for the Project(s) and No AZ DBE Firms Participated.

Submitter - Authorized Signatory I certify that my typed signature is a legally-binding signature.

Please Leave Blank

I certify that my typed signature is a legally-binding signature.

White Field = Entry in Field Permitted

Pale Orange = Form Calculated field

Teal = Vendor/Customer Generated

Grey = Disregard Field

Status Reason for Rejection ADOT PM Signature Required

Please Leave Blank

Please Leave Blank Please Leave Blank

ADOT PROGRAM/PROJECT MANAGER REVIEW

Michael Nieminen, CEO

The ADOT Project Manager is required to review for each of these items. By approving this invoice, you certify these requirements are met.

Travel charges are in accordance with State/ADOT Policy

Please Leave Blank

Not FTA Funded - Please leave section below blank

Please Leave Blank Please Leave Blank

Please Leave Blank

Please Leave Blank

Invoicing aligns with Progress and Awarded Budget / Pricing

Support Documents align to Invoice and adequately supports costs

FMS PROCESSING

Status Warrant / Check / ACH Payment No and Date A/P or C/A

Processed By

Date Signed Optional - 2nd Authorized Signatory

White Label = Field Data Provided in ADOT Documentation

Docusign Envelope ID: 999110B5-379C-4304-ABAB-E764540332B0

X

Accounts Payable DocuSign

AP RECEIVED 12/6/24 12/6/2024

Agency/ORG Agency Address

ADOT Contact Telephone Contact Address

Vendor Vendor Contact

Contract No. Date Invoice 241129-3 Date 11/29/2024

Project Title Interim VPR

Action Taken:

Contract Officer Date

Describe Project Delivery Compared with Schedule:

Describe Project Outcomes Compared with Objectives:

Describe Vendor Performance

Describe the performance issue. Be accurate, complete and factual. Use an attachment if necessary.

MPD Tracking Number MPD0117-21 Geospatial Data Collection

Describe Compliance with Invoicing Requirements:

Vendor Performance Report Arizona Department of Transportation

Procurement Group 1739 W. Jackson Street, 100P

Phoenix, AZ 85007 Facsimile: 602.712.3717

This document should be used to document positive or negative performance by a contractor and to state whether corrective action is required.

Please complete & return to ADOT Procurement.

PART 1 AGENCY REPORT

Arizona Department of Transportation / Multimodal Planning Division Mail Drop 310B, 206 S. 17th Avenue, Phoenix, AZ 85007

International Cybernetics Corp Michael Nieminen / financeadmin@icc-ims.com

CTR059565 PO Number PO0000663201

PART 2 – ADOT PROCUREMENT ACTION

Date of Action

Signature of Agency Representative Date

Reporting incident, no action requested.

Specific action requested:

Docusign Envelope ID: 999110B5-379C-4304-ABAB-E764540332B0

Invoicing requirements were met.

12/6/2024

480.670.6021

Project Objectives have been met.

X

1611 W Jackson St, Phoenix, AZ 85007Robert Bush

Performance is within expected standards.

Project Delivery was within the agreed upon schedule.

Prime Firm Name

International Cybernetics Company, LP

No DBE % 0.00%

Task No

Awarded $ Functional Role Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual

Michael Nieminen Project Management 16 40 30.0 24 24 24 40 40 24 24 32

Geoff Dew PM Duties and Data Processing 16 56 98.0 40 200 316.0 24 80 40 29.0 80 80 16

Andrew Minty GIS Specialist 56 20.0 24 120 40.0 40 90.0 95.0 Donna Daniels Data Processing 40 160 687.0 40 95.0 24 82.0 92 16

Chase Fleeman Field Operations 16 40 16

James Erskine Data Quality Assurance 16 32 120 679.6 24

Danillo Balzarini Data Quality Assurance 16 32 6.0 120 705.7 184 40

Paul Voicu Software Support 48.0 56

Adam Kennedy Field Operations 16 96

Marc Morin Field Operations 40

Field Operator Equipment Operator 8 1369 891.5 316

Field Operator Equipment Operator 8 1369 787.5 316

Michael Robson Subject Matter Expertise 16 8 8 8 24 16 32 56

Sub Firm Name Roadway Assets Services

(RAS)

No DBE % 0.00%

Task No

Awarded $ Functional Role Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual

Scot Gordon Data Quailty 16 32 16 40 16

Tom Brenneman GIS Task Assistance 24 16

Rafeal Rivera Field Operations 16 24 40 40 8.0 16

Purchase Order: Release No Vendor's Invoice No

Total Project Award 929,955.61$

$ of Contract Award $ -

Vendor Hours Contribution Table & DBE Compliance Report MPD Tracking Number MPD0117-21 Race Conscious DBE Goal Commitment 0

PO0000663201

241031-6

AZ Certified

DBE?

Client Meetings

Project

Initiation Meeting

Project Setup Pavement Data

Collection

Pavement Data- Image Log-GPS

Delivery HPMS Delivery dTims PMS Delivery

Data QA/QC and Accuracy Verification

GPR Collection (HPMS Panels)

GPR Data Analysis

$ of Contract Award $ - AZ Certified

DBE?

Project Initiation Meeting

Project Setup Pavement Data

Collection

Pavement Data- Image Log-GPS

Delivery HPMS Delivery dTims PMS Delivery

Data QA/QC and Accuracy Verification

GPR Collection (HPMS Panels)

GPR Data Analysis

Client Meetings

The hours reported on this table are provided to enable visual assessment by the ADOT Project Manager of progress on work tasks.

Decreases in DBE Firm Participation or Removal MUST be Authorized by the BECO Office in Advance.

DBE System

Vendor ID Number

DBE Compliance Contact Email

Staff Name

DBE System Vendor

ID Number

DBE Compliance Contact Email

Staff Name

Docusign Envelope ID: 999110B5-379C-4304-ABAB-E764540332B0

Bart Williamson Project Management 16 24 8 24

Collection Team Equipment Operator 675

Collection Team Equipment Operator 675

Sub Firm Name Quality Engineering Solutions

(QES)

No DBE % 0.00%

Task No

Awarded $ Functional Role Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual Plan Actual

Doug Frith Quality Assurance Manager 8 40 8

Ryan Finley Quality Assurance Engineer 40

Analysts Quality Assurance Analysts 60

136.00 0.00 488.00 154.00 4432.00 1679.00 612.00 1051.00 136.00 185.00 152.00 0.00 384.00 ###### 752.00 0.00 468.00 0.00 264.00 0.00 0.00 0.00

AZ Certified

DBE?

Project Initiation Meeting

Project Setup Pavement Data

Collection

Pavement Data- Image Log-GPS

Delivery HPMS Delivery dTims PMS Delivery

Data QA/QC and Accuracy Verification

GPR Collection (HPMS Panels)

GPR Data Analysis

Client Meetings

DBE System Vendor

ID Number

DBE Compliance Contact Email

$ of Contract Award

Staff Name

TOTALS

International Cybernetics Company, LP 10630 75th St

Largo, FL 33777 US ar@icc-ims.com www.icc-ims.com

INVOICE

BILL TO

Arizona Dept. of Transportation Multimodal Planning Division 1611 W Jackson St, MD 310B Phoenix, Arizona 85007 US

SHIP TO

Arizona Dept. of Transportation Multimodal Planning Division 1611 W Jackson St, MD 310B Phoenix, Arizona 85007 US

INVOICE 241129-3

DATE 11/29/2024

TERMS Net 30

DUE DATE 12/29/2024

CUST PO

PO0000663201

INCOTERMS

N/A - Services

QTY DUE RATE AMOUNT

IRISPro Services-State dTims PMS Delivery (Use per ADOT for Year 3)

1 20,328.00 of 20,328.00 20,328.00 20,328.00

IRISPro Services-State HPMS Delivery (Use per ADOT for Year 3)

1 16,744.00 of 16,744.00 16,744.00 16,744.00

SUBTOTAL 37,072.00

TAX 0.00

TOTAL 37,072.00

BALANCE DUE $37,072.00