RFP_277-15-0424 _Attachment_3 _Voucher_Review_Sheet.pdf

RFP No. 277-15-0424 Health Communications and Marketing (HCM) for Public Engagement

Attachment 3: 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, Room 7-1051, 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: $_________________ Twinbrook Place, Ste. 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