Attachment_4_280-15-0451_Voucher_Review_Sheet.doc

RFP No. 280-15-0451

ATTACHMENT 4

SEQ CHAPTER \h \r 1

VOUCHER REVIEW SHEET

Contract No.: _____________________________________

Contractor: ____________________________________

DUNS No.: _____________________ 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 Payment

(N/A if Letter of Credit)

To: ___________________________ , Project Officer

From: __Sheryl Sanders , Division of Contracts Management, OFR, SAMHSA 1 Choke Cherry Road Subject: Voucher No.: ____________

Period Covered: ________________________________

Contractor Point of Contact: _____________________________ Telephone: _______________________

Project Officer:

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):

P.O. sign and date here:

Date: ____________________

Signature

To: Program Support Center: PAY THIS AMOUNT:

Division of Fiscal Services AMOUNT CLAIMED:

Room 16-23

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:

Date: ___________________ Contract Specialist