80KSC021R0022 J-D Progress Payments.pdf

CERTIFICATION OF PROGRESS PAYMENTS UNDER FIXED-PRICE CONSTRUCTION CONTRACTS

BASED ON A PERCENTAGE OR STAGE OF COMPLETION

(NOV 2014)

SECTION 1 – IDENTIFICATION INFORMATION

1. TO: NAME AND ADDRESS OF CONTRACTING

OFFICE (Include Zip Code)

2. FROM: NAME AND ADDRESS OF CONTRACTOR (INCLUDE ZIP

CODE, EMAIL ADDRESS, AND PHONE NUMBER)

3. INVOICE NUMBER: 4. INVOICE DATE:

5. CONTRACT NUMBER: 6. PROJECT LOCATION:

7. PROJECT DESCRIPTION:

SECTION 2 – STATUS OF COSTS UNDER THIS CONTRACT THROUGH________________________________

(DATE)

8. ORIGINAL CONTRACT SUM – (Enter The Original Contract Award Amount) $

9. NET CHANGES – (Enter The Net Dollar Amount Via Changes) $

10. CONTRACT SUM TO DATE – (Enter The Dollar Amount of the Contract To Date) – (ITEM 8 + 9)

11. TOTAL COMPLETED AND STORED TO DATE: $

12. RETAINANGE – (Enter The Retainage Amount) $

13. TOTAL EARNED LESS RETAINAGE – (Item 11 less 12) $

14. PROGRESS PAYMENTS PREVIOUSLY PAID: $

15. CURRENT PAYMENT DUE: (Item 13 less 14) $

16. OUTSTANDING BALANCE – (Line 10 Less 13) $

17. AMOUNT APPROVED BY THE CONTRACTING OFFICER $

18. PAYMENT CERTIFICATION:

In accordance with the FAR 52.232-5, Payments Under Fixed-Price Construction Contracts, I hereby certify, to the best of my knowledge and belief, that –

a) The amounts requested are only for performance in accordance with the specifications, terms, and conditions of the contract:

b) 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;

c) 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;

d) This certification is not to be construed as final acceptance of a subcontractor’s performance; and

e) All quality requirements associated with the progress payment CLIN , including but not limited to submission and approval of shop drawings, test reports, Operation and Maintenance (O&M) documentation, equipment and material verification, etc, have been satisfied.

(Name) (Date)

(Title)

NAME AND TITLE OF CONTRACTOR REPRESENTATIVE

SIGNING THIS FORM:

SIGNATURE:

NAME AND TITLE OF CONTRACTING OFFICER:

SIGNATURE:

Invoice Number Contract Number

BLK 18. continued –

Para e through j apply to those contracts that contain a contract clause that authorize high cost material/equipment in accordance with Payment for Material Clause in Section H of the Contract.

The following certification relates to high cost material/equipment : 1) high cost material/equipment (with unit or total costs equal to or greater than $50,000 at time of order placement), such as, steel, electrical cabling, transformers, switchgear, HVAC equipment, pumps, machinery, pipe and fittings, and precast/prestressed concrete piles, etc.; 2) long lead special order items; or 3) materials that have been fabricated off-site to the point where they are identifiable to an item of work required under this contract. All materials/equipment submitted for progress payments, must be adequately insured and protected from theft and exposure. Materials that will not be paid for prior to installation include, but are not limited to, bulk quantities such as nails, fasteners, conduits, wall board, insulation, wall covering etc.

e) Attached is a certified paid vendor invoices with canceled check showing title to the items vests with the prime contractor, and includes the value of the material and labor incorporated into the item,

f) The material/equipment will be used to perform this contract only and that; I agree that title to the material/equipment shall vest with the Government, upon payment of the requested progress payment; and that title to any excess material/equipment will vest with the contractor upon the completion and acceptance of the CLIN.

g) The material/equipment conforms to contract requirements and is documented on the Government approved shop drawing(s) for this contract,

h) The attached inventory checklists has been jointly validated by the contractor, contract administrator, and/or Government construction inspector,

i) The attached accepted delivery tickets states the delivery location, and

j) The material/equipment shall not be removed from the delivery location without prior written permission of the Contracting Officer.

CERTIFIED BY:

Signature Signature

Title Quality Manager

Name and Address of Contractor Date

Date

STATEMENT OF VALUES

Project/Job Name: Payment/Application Number:

Contract Number: Payment/Application Date:

PCN Number: Period Through Date:

Item No.

Description of Work

Scheduled Value

Work Completed Total Completed and Stored to

Date % Balance to

Finish Previous

Application

Completed This

Period

Materials Presently

Stored

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

0.00 0.00% 0.00

Totals 0 0 0 0 0 0 0

SUBCONTRACTOR PAYMENT SCHEDULE

DATE: PROGRESS PAYMENT #:

CONTRACTOR:

CONTRACT #: DELIVERY ORDER #:

SUBCONTRACTOR

NAME

SUBCONTRACT

AMOUNT

AMOUNT

PAID TO

DATE

DUE

THIS

PERIOD

TOTAL

PAYMENTS

Authorized High Cost Material/Equipment – Payments to Subcontractors

Name of SubContractor

Date Paid

Voucher No.

or Reference

Check Number

Contract Value

Amt.

Withheld

Amt. Pd

TOTAL

CLIN Retainage Summary

10% of completed work $ 10% of approved material $

Total CLIN Retainage Withheld $

Total remaining CLIN retainage to be paid $