Exhibit G VA PAY FORM w Monthly checklist A0016.pdf

VA Pay Form

Contractor: ____________________________ Contract No.: ________________________

_____________________________ Project No.: ________________________

______________________________ Period Ending: ________________________

Request No.: _________________________

Date of Request: __________________________

Project Title: ______________________________________________________ ___________________

PROGRESS PAYMENT

Original Contract Amount: $________________________

Increases Authorized: $________________________

Decreases Authorized: $________________________

Current Contract Amount: $________________________

Activities Completed to Date: $________________________

Less Retainage: $________________________

Less Previous Payments: $________________________

Amount Recommended for Payment: $________________________

Contract Balance: $________________________

CERTIFICATION

I hereby certify, to the best of my knowledge and belief, that-

(1) The amounts requested are only for performance in accordance with the specifications, terms, and conditions of the contract;

(2) All payments due to subcontractors and suppliers from previous payments received under the contract have been made, and timely payments will be made from the proceeds of the payment covered by this certification, in accordance with subcontract agreements and the requirements of Chapter 39 of Title 31, United States Code;

(3) This request for progress payments does not include any amounts which the prime contractor intends to withhold or retain from a subcontractor or supplier in accordance with the terms and conditions of the subcontract; and

(4) This certification is not to be construed as final acceptance of a subcontractor’s performance.

NAME – SIGNATURE TITLE DATE

I have reviewed this payment request and agree that the Contractor is entitled to payment in the amount shown above.

Date

Date

Construction Representative

Contracting Officer’s Representative

Contracting Officer/Contract Specialist Date

Monthly Submittal Checklist Submittals required prior to pay request approval

Item Date Submitted

PM

Initial

COR /CO

Initial

Daily Production Reports 852.236-79

Daily Safety Inspection Reports 01 35 26 1.9A

Certified Safety Professional (CSP) Monthly Site Safety Inspection 01 35 26 1.9B Exposure Hours – 01 35 26 1.10.C

Quality Control Reports 01 45 00 3.9A

Updated Schedule – 013216.15 para 1.4.A

Waste Manifests – 017419 para 1.5.D

Monthly As-built Update – 01 00 00 1.14B, 01 00 00 1.15B

Weekly Certified Payrolls – FAR 52.222-8

Warranty Information – 010000 para 1.16.A

Sustainable Construction Progress Reports – 018113 para 1.5.F

COR/CO and PM may agree that a submittal is not applicable to the project or to the current month.