Atch_3_-_ARS-372_Contractor_Request_for_Payment.pdf

PDF 112 KB Posted

Attached to
Replacing Fire Alarm System Federal contract opportunity
Solicitation number
AG-32SC-S-15-0035
Issued by
Department of Agriculture Agricultural Research Service Central Program Planning Coordination and Support

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Attachment 3

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Other files attached to Replacing Fire Alarm System, newest first.
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SF_30_Amendment_0005.pdf PDF
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Revised_SOW_-_Replace_Fire_Alarm_System _Gainesville _FL_25_Aug_2015.pdf PDF
Atch_2_-_Statement_of_Work_dated_18_August_2015.pdf PDF
SF_30_Amendment_0002.pdf PDF
Atch_1_-_Facility_Wide_Fire_Alarm_Drawings_14_Aug_15.pdf PDF
Amendment_0001.pdf PDF
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AG-32SC-S-15-0035_Replace_Fire_Alarm_System-_Gainesville _FL.pdf PDF
Atch_2_-_ARS-371_Construction_Progress_and_Payment_Schedule.pdf PDF
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CONTRACTOR'S REQUEST FOR PAYMENT TRANSMITTAL

CONTRACT NO.

PROJECT

LOCATION

PARTIAL PAYMENT NO.

REQUISITION NO.

FOR PERIOD BEGINNING

ENDING

FINAL PAYMENT

ITEM

AMOUNT

1. Amount of original contract

2. Change orders and/or amendments

3. Total adjusted contract prices

4. Value of work completed to end of period

5. Value of material stored at the site (Itemize below)

6. Total value of work completed and stored material (Line 4 plus Line 5).

8. Total due contractor thru end of this period

9. Less previous requests

10. Net amount due contractor this payment

7. Less MATERIAL STORED AT THE SITE (See Item 5 above) Description Value

CONTRACTOR'S CERTIFICATION OF PAYMENT

By signing this request for payment, I certify that I have made payment from the proceeds of prior payments, and that I will make timely payment from the proceeds of this payment, of amounts due my subcontractors and suppliers in accordance with my contractual arrangements with them.

SIGNATURE OF CONTRACTOR'S AUTHORIZED REPRESENTATIVE

RECOMMENDED FOR PAYMENT (Signature of EPM, COR, CM or A.E. as ppropriate) CONCUR (Signature of EPM or COR as appropriate)

DATE SIGNED

DATE SIGNED

DATE SIGNED

Form ARS-372 (11/84) Replaces SEA-372 (1/79) which may be used.

USDA-ARS

This form was electronically produced by USDA/ARS/OCIO/ADB.

% retainage

ffSignImage01:
ffSignImage02:
ffSignImage03:
Check if Final payment.: 0
Enter date for period beginning using format MM/DD/YYYY.:
Enter date for period ending using format MM/DD/YYYY.:
Item. 1. Amount of original contract.:
Item 2. Change orders and / or amendments.:
Item 3. Total adjusted contract prices.:
Item 4. Value of work completed to end of period.:
Item 5. Value of material stored at the site (Itemize below).:
Item 6. Total value of work completed and stored material (Line 4 plus Line 5). Value of material stored at the site (Itemize below).:
Item 7. Enter Percent retainage.:
Item 7. Less indicated percentage retainage.:
Item 8. Total due contractor thru end of this period.:
Item 9. Less previous requests.:
Item 10. Net amount due contractor this payment.:
Value. Line 1.:
Value. Line 2.:
Value. Line 3.:
Value. Line 4.:
Value. Line 5.:
Value. Line 6.:
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Contractor's request for payment transmittal. Enter contract number.:
Partial payment number.:
Project.:
Requisition number.:
Location.:
Description. Line 1.:
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Click to return to catalog:
Click to save form:
Save As:
Click to route form:
Click to print form:
BtnNam:
Name of record:
UserName: Richard T Stevens
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fscSubmitURL: https://reeforms.ars.usda.gov/REEForms/ffSubmitXFA.asp?id=5EE57F3651A194D0C1F8EF5FA8D8CE418134079C29C14B2CD15CD8E4CDB4B430D83001055FF352CB56C7192B7905F3646623C6608706C8D5BB97011F3B1FC56749B93A87D4249481
FormFields:
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SignatureField: ARSNET-Trent.Stevens
CLICK TO SIGN FORM:
ffSignLockFields01:
CLICK TO CLEAR SIGNATURE:
ffSignInfo01:
ffSignDate01:
SIGNATURE AND TITLE:
SIGNATURE AND TITLE:
CLICK TO CLEAR SIGNATURE:
CLICK TO SIGN FORM:
ffSignLockFields02:
ffSignInfo02:
ffSignDate02:
SIGNATURE AND TITLE:
SIGNATURE AND TITLE:
CLICK TO CLEAR SIGNATURE:
CLICK TO SIGN FORM:
ffSignLockFields03:
ffSignInfo03:
ffSignDate03:
SIGNATURE AND TITLE:
SIGNATURE AND TITLE:

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