Attachment 4 Pay Request (Constr) Form.xls
XLS spreadsheet 119 KB Posted
- Attached to
- Cheyenne River Quarters French Door Replacement
- Solicitation number
- 75H70124R00053
About this file
This document is an Application for Payment Contractor's Application for Payment form, which is used to request progress payments under a federal construction contract. The form includes sections for the contractor to provide details on the original contract amount, contract modifications, completed work, payments to subcontractors, and the net payment requested. It also includes certifications the contractor must provide per FAR 52.232-5.
The related federal contract opportunity is for the replacement of French doors throughout the quarters of the Cheyenne River Health Center in Eagle Butte, SD. This is a 100% Small Business set-aside construction project under NAICS code 236220, with an anticipated contract value between $500,000 and $1,000,000. The period of performance is 365 calendar days and the contract type is Firm Fixed Price. Proposals will be evaluated on the Lowest Price Technically Acceptable basis.
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Other files
| File | Type | Posted |
|---|---|---|
| B05 24R00053 Amendment 2.pdf | ||
| B05 24R00053 Amendment 1.pdf | ||
| B01 24R00053.pdf | ||
| Attachment 5 Release of Claims.pdf | ||
| Attachment 2 IHS GPA Eagle Butte Quarters Map.pdf | ||
| Attachment 6 Self Performed Calculation Sheet.docx | DOCX document | |
| Attachment 1 Wage Determination SD20240012.pdf | ||
| Attachment 3 WH347 Certified Payroll.pdf | ||
| Attachment 7 PPQ.docx | DOCX document |
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Text version
Application for Payment
| Contractor's Application for Payment | ||||
| Progress Payment / Invoice #: | Date: | |||
| Contractor Name: | Contract Number: | |||
| Contractor Address: | Task/Delivery Order Number: | |||
| Contractor TIN / SAM UEI: | Project Title: |
Location:
| To be completed by the Contractor: | To be completed by the Government: | ||||
| 1. | Original Contract Amount (Part A Column F) | $ - 0 | (Enter amount from item 10) | $ - 0 | |
| 2. | Net Change by Modifications (Part B Column F) | $ - 0 | |||
| 3. | Adjusted Contract Amount to Date (1 + 2) | $ - 0 | 11. | Amount retained by Government per FAR 52.232-5 (e) | $ - 0 |
| 4. | Original Contract Work Complete (Part A Column K) | $ - 0 | Explanation of withheld amount: | ||
| 5. | Modification Work Complete (Part B Column J) | $ - 0 | |||
| $ - 0 | |||||
| 6. | Total Progress (4 + 5) | $ - 0 | |||
| 7. | Subcontract Retention (Part C Column G) | $ - 0 | |||
| 8. | Net Earned Progress (6 - 7) | $ - 0 | 12. | Balance Due This Pay Request (10 - 11) | $ - 0 |
| 9. | Previous Payments | $ - 0 | |||
| 10. | Net Payment Requested (8 - 9) | $ - 0 | |||
| Contractor Certification Per FAR 52.232-5 (c) | |||||
| Per FAR 52.232-5(c) the Contractor shall furnish the following certification, or payment shall not be made: (However, if the Contractor elects to delete paragraph (c)(4) from thecertification, the certification is still acceptable.) |
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) Payments to subcontractors and suppliers have been made from previous payments received under the contract, 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.
| Printed Name / Signature / Title | Date | |
| Contractor Must Answer: | ||
| Small Business: | Y / N | |
| Tripartite / 3rd Party Agreement: | Y / N | |
| Final Payment: | Y / N | |
| MUST Include Release of Claims (ROC) with Final Payments |
Indian Health Service
DEPARTMENT OF HEALTH & HUMAN SERVICES
Pay Request Part A (orig)
| Progress Payment / Invoice Number: | Date: | |||||||||
| Name of Contractor | Contract Number | |||||||||
| Part A: Completed Work Under Original Contract | ||||||||||
| A | B | C | D | E | F | G | H | I | J | K |
| Item No. | Description of Item | Quantity | Unit of Issue | Unit Cost | Total Cost | Percentage or Estimated Amounts Installed | Payments | Total to Date | ||
| Previous | This Period | Previous | This Period | |||||||
| 1 | General Conditions | |||||||||
| 2 | Mobilization | |||||||||
| 3 | Demobilization - Closeout | |||||||||
| 4 | Additional Line Items 4 through _____ | |||||||||
| Contractors G&L Insurance & Bonds | ||||||||||
| TERO | ||||||||||
| TOTAL CONTRACT AMOUNT |
Indian Health Service
DEPARTMENT OF HEALTH & HUMAN SERVICES
Pay Request Part B(mods)
| Progress Payment / Invoice Number: | Date: | ||||||||
| Name of Contractor | Contract Number | ||||||||
| Part B: Contract Modifications | |||||||||
| A | B | C | D | E | F | G | H | I | J |
| Mod No. | Date | Description of Item | Quantity & Unit of Issue | Unit Cost | Total Cost | Completed | Stored Materials | Total Completed & Stored | |
| Previous | This Period | ||||||||
| TOTALS |
Indian Health Service
DEPARTMENT OF HEALTH & HUMAN SERVICES
Pay Request Part C (subs)
| Progress Payment / Invoice Number: | Date: | ||||||
| Name of Contractor | Contract Number | ||||||
| Part C: Payments to Subcontractors | |||||||
| A | B | C | D | E | F | G | H |
| Item No. | Subcontractor Name | Subcontract Amount Including Changes | Progress | Retention in Accordance with Subcontract Terms | Net Due to Subcontractor Through This Application for Payment | ||
| Previous | This Period | Total | |||||
| TOTALS |
Indian Health Service
DEPARTMENT OF HEALTH & HUMAN SERVICES
File details come from the government source that posted it. Updated .