Attachment 3 VA Pay Form.pdf
PDF 120 KB Posted
- Attached to
- Z2DA--VA Central Western Massachusetts Healthcare System (HCS) – Single Award Task Order Contracts (SATOC)
- Solicitation number
- 36C24125R0068
About this file
The document is a VA Pay Form for a progress payment, designed to track contract payment details and certify compliance with contract terms. The form includes sections for recording contract financial information such as original contract amount, authorized increases/decreases, current contract amount, activities completed to date, retainage, and previous payments. The form requires certification by the contractor, who must confirm that requested amounts are for performance in accordance with contract specifications, all subcontractor payments have been made, and the payment request does not include any withheld subcontractor funds.
Additionally, the document includes a Monthly Submittal Checklist detailing required documentation prior to pay request approval. The checklist covers various reports and documentation that must be submitted, including daily production reports, safety inspection reports, quality control reports, updated schedules, waste manifests, as-built updates, weekly certified payrolls, warranty information, and sustainable construction progress reports. The checklist provides space for recording submission dates and obtaining initials from the Project Manager (PM), Contracting Officer's Representative (COR), and Contracting Officer (CO).
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24125R0068 0001.docx | DOCX document | |
| 36C24125R0068 Solicitation.pdf | ||
| SATOC Statement of Work CWM Rev1.pdf | ||
| Seed Project 631-25-004 SOW All Work.pdf | ||
| 36C24125R0068 Solicitation.docx | DOCX document | |
| Attch C-Specifications.pdf | ||
| Attch A-Full Drawing Set.pdf | ||
| Wage Determination MA20240003.pdf | ||
| Attachment 1 VHA ICRA.pdf | ||
| Combined SATOC Specs.pdf | ||
| Attachment 2 PPQ.pdf | ||
| Attch B-Appendix A Supplemental Requirements.pdf | ||
| RS Means Seed Project Example.xlsx | XLSX spreadsheet |
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Text version
Attachment 3 VA Pay Form
Contractor: ____________________________ Contract No.: ________________________
_____________________________ Project No.: ________________________
______________________________ Period Ending: ________________________
Request No.: _________________________
Date of Request: __________________________
Project Title: ______________________________________________________ ___________________
PROGRESS PAYMENT
Original Contract Amount: $________________________
Increases Authorized: $________________________
Decreases Authorized: $________________________
Current Contract Amount: $________________________
Activities Completed to Date: $________________________
Less Retainage: $________________________
Less Previous Payments: $________________________
Amount Recommended for Payment: $________________________
Contract Balance: $________________________
CERTIFICATION
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 this 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.
NAME – SIGNATURE TITLE DATE
I have reviewed this payment request and agree that the Contractor is entitled to payment in the amount shown above.
Construction Representative Date
Contracting Officer’s Representative Date
Contracting Officer/Contract Specialist Date
Monthly Submittal Checklist Submittals required prior to pay request approval
Item
Date Submitted
PM
Initial
COR /CO
Initial
Daily Production Reports 852.236-79
Daily Safety Inspection Reports 01 35 26 1.9A
Certified Safety Professional (CSP) Monthly Site Safety Inspection 01 35 26 1.9B
Exposure Hours – 01 35 26 1.10.C
Quality Control Reports 01 45 00 3.9A
Updated Schedule – 013216.15 para 1.4.A
Waste Manifests – 017419 para 1.5.D
Monthly As-built Update – 01 00 00 1.14B, 01 00 00 1.15B
Weekly Certified Payrolls – FAR 52.222-8
Warranty Information – 010000 para 1.16.A
Sustainable Construction Progress Reports – 018113 para 1.5.F
COR/CO and PM may agree that a submittal is not applicable to the project or to the current month.
File details come from the government source that posted it. Updated .