Attachment 5 Pay Request Form.pdf
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- Solicitation number
- 80KSC026R0012
About this file
This document is a Certification of Progress Payments form for a fixed-price construction contract, designed to track and certify partial payments during project execution. The form includes detailed financial sections that allow contractors to document contract value, completed work, retainage, and payment calculations, with specific certification statements required by Federal Acquisition Regulation (FAR) 52.232-5. The document comprises three key components: a progress payment certification form, a statement of values table (currently blank), and a subcontractor payment schedule template, which together provide a comprehensive framework for tracking and documenting contract progress, work completion percentages, and payments to the primary contractor and subcontractors.
The certification includes critical attestations by the contractor, including confirmation that: requested amounts are for performance per contract specifications, all subcontractor payments have been or will be made timely, no amounts are being improperly withheld from subcontractors, the certification is not a final acceptance of subcontractor performance, and all quality requirements associated with the progress payment have been satisfied. The form requires signatures from both the contractor representative and the contracting officer, emphasizing the formal and legally binding nature of the progress payment documentation.
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Text version
CERTIFICATION OF PROGRESS PAYMENTS
UNDER FIXED-PRICE CONSTRUCTION CONTRACTS
BASED ON A PERCENTAGE OR STAGE OF COMPLETION
SECTION 1 – IDENTIFICATION INFORMATION
1. TO: NAME AND ADDRESS OF CONTRACTING
OFFICE (Include Zip Code)
2. FROM: NAME AND ADDRESS OF CONTRACTOR (INCLUDE ZIP
CODE, EMAIL ADDRESS, AND PHONE NUMBER)
3. INVOICE NUMBER: 4. INVOICE DATE:
5. CONTRACT NUMBER: 6. PROJECT LOCATION:
7. PROJECT DESCRIPTION:
SECTION 2 – STATEMENT OF COSTS UNDER THIS CONTRACT THROUGH________________________________
(DATE)
8. ORIGINAL CONTRACT SUM – (Enter The Original Contract Award Amount) $
9. NET CHANGE ORDERS – (Enter The Net Dollar Amount Via Change Orders) $
10. CONTRACT SUM TO DATE – (Enter The Dollar Amount of the Contract To Date) – (ITEM 9 + 10)
11. TOTAL COMPLETED AND STORED TO DATE: $
12. RETAINANGE – (Enter The Retainage Amount) $
13. TOTAL EARNED LESS RETAINAGE – (Item 12 less 13) $
14. PROGRESS PAYMENTS PREVIOUSLY PAID: $
15. CURRENT PAYMENT DUE: (Item 14 less 15) $
16. BALANCE TO FINISH, INCLUDING RETAINAGE – (Line 11 Less 14) $
17. AMOUNT APPROVED BY THE CONTRACTING OFFICER $
18. PAYMENT CERTIFICATION:
In accordance with the FAR 52.232-5, Payments Under Fixed-Price Construction Contracts, I hereby certify, to the best of my knowledge and belief, that –
a) The amounts requested are only for performance in accordance with the specifications, terms, and conditions of the contract:
b) 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;
c) 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;
d) This certification is not to be construed as final acceptance of a subcontractor’s performance; and
e) All quality requirements associated with the progress payment CLIN , including but not limited to submission and approval of shop drawings, test reports, Operation and Maintenance (O&M) documentation, equipment and material verification, etc, have been satisfied.
(Name) (Date)
(Title)
NAME AND TITLE OF CONTRACTOR REPRESENTATIVE
SIGNING THIS FORM:
SIGNATURE:
NAME AND TITLE OF CONTRACTING OFFICER:
SIGNATURE:
STATEMENT OF VALUES
Project/Job Name: Payment/Application Number:
Contract Number: Payment/Application Date:
PCN Number: Period Through Date:
Item No.
Description of Work
Scheduled Value
Work Completed Total Completed and Stored to
Date % Balance to
Finish Previous
Application
Completed This
Period
Materials Presently
Stored
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
0.00 0.00% 0.00
Totals 0 0 0 0 0 0 0
SUBCONTRACTOR PAYMENT SCHEDULE
DATE: PROGRESS PAYMENT #:
CONTRACTOR:
CONTRACT #: DELIVERY ORDER #:
SUBCONTRACTOR
NAME
SUBCONTRACT
AMOUNT
AMOUNT
PAID TO
DATE
DUE
THIS
PERIOD
TOTAL
PAYMENTS
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