Ars372 (with Certs).xls
XLS spreadsheet 35 KB Posted
- Attached to
- Sidewalk Repair at National Agriculture Library
- Solicitation number
- 1232SA23Q0107
About this file
This document contains a contractor payment request form and details of a related federal contract opportunity for sidewalk repair. The payment request form is used by contractors to request partial or final payment on a contract and includes fields for the original contract amount, change orders, total adjusted price, work completed to date, stored materials, retainage, total due, and previous payments. The related federal solicitation is for sidewalk repair at the National Agriculture Library from the Department of Agriculture Agricultural Research Service. The solicitation number is 1232SA23Q0107 and is for a fixed-price contract to repair sidewalks. The response due date and award date are not provided.
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Text version
Sheet1
| CONTRACTOR'S REQUEST FOR PAYMENT TRANSMITTAL | |||
| CONTRACT NO. | PARTIAL PAYMENT NO. | FINAL PAYMENT | � |
| PROJECT | REQUISITION NO. | ||
| LOCATION | FOR PERIOD BEGINNING | ENDING | |
| 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) | $ | ||
| 7. Less % retainage | $ | ||
| 8. Total due contractor through end of this period | $ | ||
| 9. Less previous requests | $ | ||
| 10. Net amount due contractor this payment | $ | ||
| MATERIAL STORED AT THE SITE (See Item 5 above) | |||
| Description | Value | ||
| CONTRACTOR'S CERTIFICATION OF PAYMENT | |||
| 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 the 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. | |||
| SIGNATURE OF CONTRACTOR'S AUTHORIZED REPRESENTATIVE | DATE SIGNED | ||
| RECOMMENDED FOR PAYMENT (Signature of EPM, COR, CM, or A.E. as appropriate) | DATE SIGNED | ||
| CONCUR (Signature of EPM or COR as appropriate) | DATE SIGNED | ||
| FORM ARS-372 (11/84) Replaces SEA-372 (1/79) which may not be used. | USDA-ARS |
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File details come from the government source that posted it. Updated .