Ars372.pdf

CONTRACT NO. PARTIAL PAYMENT NO. FINAL PAYMENT

PROJECT REQUISITION NO.

LOCATION FOR PERIOD BEGINNING

ITEM

1. Amount of original contract $

2. Change orders and/or amendments $

3. Total adjusted contract prices $

7. Less % retainage

USDA-ARSFORM ARS-372 (11/84) Replaces SEA-372 (1/79) which may not be used.

CONTRACTOR'S REQUEST FOR PAYMENT TRANSMITTAL

DATE SIGNED

DATE SIGNED

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

CONCUR (Signature of EPM or COR as appropriate) 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 DATE SIGNED

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

MATERIAL STORED AT THE SITE (See Item 5 above)

Description Value

10. Net amount due contractor this payment

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

8. Total due contractor through end of this period

9. Less previous requests

AMOUNT

4. Value of work completed to end of period

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

ENDING

Sheet1