Attachment 6 - ARS 372.pdf
PDF 18 KB Posted
- Solicitation number
- 12905B20R0013
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Text version
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 |
File details come from the government source that posted it. Updated .