270-15-0459_Attach_4_Voucher_Review_Sheet.docx
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- Attached to
- Data Waiver and Processing Project Federal contract opportunity
- Solicitation number
- 270-15-0459
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Attachment 4 - Voucher Review Sheet
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RFP No. 270-15-0459 Data Waiver and Processing Project Attachment 4: Voucher Review Sheet
VOUCHER REVIEW SHEET
Contract No.: ____________________ Reference No.: ___________________ Contractor: _____________________ DUNS # ___________
| Received in DCM/OFR: (Contractor fills in) | x Cost Reimbursement | |||
| Today's Date: | Fixed Price | |||
| Date Due In DCM: | IQC Work Order | |||
| Date Due In PSC/DFS: | Letter of Credit | |||
| Time-and-Material/Labor-Hour |
Contract Financing Payment (N/A if Letter of Credit) To: _____________, Contracting Officer’s Representative (COR)
From: _____________, Division of Contracts Management, OFR, SAMHSA, 1 Choke Cherry Rd, Rm _____
| Subject: Voucher No.: | (Contractor fills in) |
| Amount: $ | Period Covered: |
Contractor Point of Contact: ____________________ Telephone: ________________
COR:
Please review the Voucher, answer the following and return to DCM by date shown above.
YES NO
1. Are costs commensurate with efforts expended? ________ ________
2. Are all elements of cost reasonable, in support of contract performance and
| consistent with amounts negotiated? | ________ | ________ | ||||
| 3. Have deliverables received during the period been timely and acceptable | ________ | ________ | ||||
| 4. Do you recommend payment be made as claimed? | ________ | ________ | ||||
| 5. Do you question any costs claimed? If yes, explain below. | ________ | ________ |
(ATTACH ADDITIONAL SHEET OF PAPER IF NEEDED):
| COR sign and date here: | _____________ | ||
| Signature | Date |
| To: Program Support Center: | PAY THIS AMOUNT: | $_________________ |
| DFO Accounting Operations | AMOUNT CLAIMED: | $_________________ |
| Suite 200 | AMOUNT TO BE SUSPENDED FROM PAYMENT: $_________________ |
In accordance with the Prompt Payment Provisions (Subsection (b)(4)), INTEREST __IS, __ IS NOT payable under this Invoice or Contract Financing Payment. TO BE PAID NOT LATER THAN ________________.
* NOTE: THIS INVOICE/VOUCHER IS APPROVED FOR PROVISIONAL PAYMENT ONLY. All payments are subject to change pending final audit.
Reason for Suspension:
| Approved for payment: _____________________________________________ | _____________ | |
| Contract Specialist | Date |
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