Attachment 6 - ARS-372 Request for Payment.pdf
PDF 71 KB Posted
- Attached to
- Edinburg, TX Fencing Project
- Solicitation number
- 12805B23Q0937
About this file
This document is a contractor's request for payment form related to Solicitation Number 12805B23Q0937 for an Edinburg, TX fencing project from the Department of Agriculture Agricultural Research Service Field Research Implementation and Information Delivery Plains Area. The form requests payment of $71,000 for work completed through the period ending March 15th, 2023, including $65,000 for installation of new fencing materials and $6,000 for stored fencing supplies. The contractor certifies that subcontractors have been paid for previous work and will be paid from the proceeds of this request, and that the amounts requested are only for contract performance and do not include any funds intended to be withheld from subcontractors. Recommendation and concurrence signatures are required from the EPM, COR, CM or A-E before payment can be processed.
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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
MATERIAL STORED AT THE SITE (See Item 5 above)
Description Value
CONTRACTOR'S PROGRESS PAYMENT CERTIFICATION
SIGNATURE OF CONTRACTOR'S AUTHORIZED REPRESENTATIVE
RECOMMENDED FOR PAYMENT (Signature of EPM, COR, CM or A-E as appropriate)
CONCUR (Signature of EPM or COR as appropriate)
DATE SIGNED
DATE SIGNED
DATE SIGNED
Form ARS-372 (06/2011) USDA-ARS This form was electronically produced by USDA/ARS/OCIO/EASB.
% retainage
The amounts requested are only for performance in accordance with the specifications, terms, and conditions of the contract;(1)
(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 This certification is not to be construed as final acceptance of a subcontractor's performance.(4)
I hereby certify, to the best of my knowledge and belief, that -
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