ARS 372 CONTRACTORS REQUEST FOR PAYMENT TRANSMITTAL.pdf

PDF 18 KB Posted

Attached to
Laboratory Remodel Kimberly ID Federal contract opportunity
Solicitation number
12905B21Q0007
Issued by
Department of Agriculture Agricultural Research Service Field Research Implementation and Information Delivery Pacific West Area

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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 % retainage

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 con-tractual 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/ITD using InForms software.

CONTRACT NO:
PROJECT:
1 Amount of original contract:
fill_6:
2 Change orders andor amendments:
fill_7:
3 Total adjusted contract prices:
fill_8:
fill_15:
fill_17:
fill_18:
undefined_2:
fill_20:
fill_22:
fill_24:
fill_26:
DescriptionRow1:
ValueRow1:
CONCUR Signature of Contractor:
CONCUR Signature of EPM or COR as appropriate:
CONCUR Signature of EPM:
DATE SIGNED:
DATE SIGNED 2:
DATE SIGNED 1:
Text1:
Text2:
Text3:
Text4:
Text5:
Check Box6: Off

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