Attachment 6 ARS_372_REQUEST FOR PAYMENT TRANSMITTAL.pdf
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- 1232SA26Q0224
About this file
This is a Contractor's Request for Payment Transmittal form (Form ARS-372) used by the USDA Agricultural Research Service to process progress and final payments for federal contracts.
The form enables contractors to request payment by documenting the original contract amount, any change orders or amendments, the total adjusted contract price, and the value of work completed during the payment period. Line items account for material stored at the site, with a deduction for retainage percentage as specified in the contract. The form calculates the total amount due to the contractor through the end of the period, subtracts previous payment requests, and determines the net amount due for the current payment. Contractors must itemize any stored materials with descriptions and values. The form includes a certification section where the contractor's authorized representative attests that requested amounts comply with contract specifications, all subcontractor and supplier payments from prior invoices have been made in accordance with Chapter 39 of Title 31, United States Code, and no amounts are being improperly withheld from subcontractors or suppliers. The form requires three signature blocks: the contractor's authorized representative, a recommending official (EPM, COR, CM, or A-E), and a concurring official (EPM or COR), each with corresponding date fields.
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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 -
Previous edition is not usable.
c:\\docume~1\\admini~1.for\\mydocu~1\\accounts\\usda2\\origin~1\\set3~1\\ars372.wpf Administrator D:20050417122932- 04'00' D:20050426102902- 04'00'
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 - Previous edition is not usable.
| Check if Final payment.: 0 |
| Enter date for period beginning using format MM/DD/YYYY.: |
| Enter date for period ending using format MM/DD/YYYY.: |
| Item. 1. Amount of original contract.: |
| Item 2. Change orders and / or amendments.: |
| Item 3. Total adjusted contract prices.: |
| Item 4. Value of work completed to end of period.: |
| Item 5. Value of material stored at the site (Itemize below).: |
| Item 6. Total value of work completed and stored material (Line 4 plus Line 5). Value of material stored at the site (Itemize below).: |
| Item 7. Enter Percent retainage.: |
| Item 7. Less indicated percentage retainage.: |
| Item 8. Total due contractor thru end of this period.: |
| Item 9. Less previous requests.: |
| Item 10. Net amount due contractor this payment.: |
| Value. Line 1.: |
| Value. Line 2.: |
| Value. Line 3.: |
| Value. Line 4.: |
| Value. Line 5.: |
| Value. Line 6.: |
| Value. Line 7.: |
| Value. Line 8.: |
| Value. Line 9.: |
| Contractor's request for payment transmittal. Enter contract number.: |
| Partial payment number.: |
| Project.: |
| Requisition number.: |
| Location.: |
| Description. Line 1.: |
| Description. Line 2.: |
| Description. Line 3.: |
| Description. Line 4.: |
| Description. Line 5.: |
| Description. Line 6.: |
| Description. Line 7.: |
| Description. Line 8.: |
| Description. Line 9.: |
| Value. Line 10.: |
| Value. Line 11.: |
| Value. Line 12.: |
| Value. Line 13.: |
| Value. Line 14.: |
| Value. Line 15.: |
| Value. Line 16.: |
| Value. Line 17.: |
| Description. Line 10.: |
| Description. Line 11.: |
| Description. Line 12.: |
| Description. Line 13.: |
| Description. Line 14.: |
| Description. Line 15.: |
| Description. Line 16.: |
| Description. Line 17.: |
| Enter date in this format MM/DD/YYYY: |
| Enter date in this format MM/DD/YYYY: |
| Enter date in this format MM/DD/YYYY: |
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