RFP 277-20-0550 Attachment 3 Voucher Review Sheet.pdf

RFP No. 277-20-0550 Attachment 3: Voucher Review Sheet

VOUCHER REVIEW SHEET

Contract No.: Ref. No.

Contractor:

DUNS:

Received in DCM/OFR: X Cost Reimbursement Today’s Date: Fixed Price Date Due in DCM: IQC Work Order Date Due in PSC/DFS: Letter of Credit Contract Financing (N/A if letter of credit)

To: __________________, Contracting Officer Representative (COR)

From: ____________________, Division of Contracts Management, OFR, SAMHSA, 5600 Fishers Lane

Subject: Voucher No. ________________

Period Covered: __________________________________

Contractor Point of Contract: ______________________ Telephone: _______________ Email: ________________

COR:

Please review the Voucher, answer the following question and return to DCM by the 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: ________________________________________ Date: __________________

To: Program Support Center PAY THIS AMOUNT: _______________________

DFO Accounting Operations AMOUNT CLAIMED: _______________________

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 NO 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: ______________________________________________ Date: __________________ Contract Specialist