Attachment 7 ARS-372 Request for Payment.pdf
PDF 30 KB Posted
- Attached to
- Construct Wildlife Barn Federal contract opportunity
- Solicitation number
- 12805B23R0023
About this file
This document is a contractor's request for payment form for contract number 12805B23R0023 to construct a wildlife barn for the Department of Agriculture Agricultural Research Service Field Research Implementation and Information Delivery Plains Area. It includes line items for the original contract amount, any change orders or amendments, the total adjusted contract price, the value of work completed to date, stored materials, amounts due and paid to the contractor, and percentages for retainage. The contractor is requesting payment for work performed between the dates of MM/DD/YYYY and MM/DD/YYYY. Signatures are required from the contractor and approving officials at the USDA to process payment.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| Geotechnical Engineering Report CFTRL.pdf | ||
| Questions from Industry -18 July 2023.pdf | ||
| 12805B23R0023 Amend 0002.pdf | ||
| Attachment 1 Wildlife Barn Drawings.pdf | ||
| Attachment 2 Wildlife Barn Specifications.pdf | ||
| 12805B23R0023 Through Amend 2.pdf | ||
| Site Visit Attendance.pdf | ||
| 12805B23R0023 Amend 0001.pdf | ||
| 12805B23R0023 Through Amend 1.pdf | ||
| 12805B23R0023.pdf | ||
| Exhibit A - Bid Schedule - 12805B23R0023.xlsx | XLSX spreadsheet | |
| Attachment 1 Wildlife Barn Drawings.pdf | ||
| Attachment 2 Wildlife Barn Specifications.pdf | ||
| Attachment 3 Fencing Material Specifications.docx | DOCX document | |
| Attachment 6 ARS-371 Construction Progress and Payment Schedule.pdf | ||
| Attachment 8 Template C Contractors Release of Claims.pdf | ||
| Attachment 4 Contractor Certification Regarding EMR.pdf | ||
| Attachment 5 WD TX20230255 Mod 0 Dated 6 Jan 2023.pdf |
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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.: |
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| Contractor's request for payment transmittal. Enter contract number.: |
| Partial payment number.: |
| Project.: |
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| Location.: |
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| 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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