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Instructions
| INSTRUCTIONS FOR COMPLETING PAYMENT REQUEST |
| NOTE: Form is locked. Only shaded blocks can be filled in |
| 1. The Summary tab includes contractor information, a summary of total award, and contract |
| line items (CLINs) 0001 and 0002 |
2. Complete project information and contractor information sections
| 3. Fill in the current month scheduled progress from most recent Government accepted schedule |
| Actual progress will be calculated based on individual CLIN progress |
| 4. Fill in lines for each applicable CLIN based on the number of CLINs in the contract. |
| Complete blocks A, B, D, and F for each applicable CLIN. If more than two CLINs use next tab |
5. Total will be calculated in the Overall Contract block
6. Retainage will be automatically calculated at 5% if actual progress exceeds 10% behind schedule
7. After completed, save form as a PDF file if available. Otherwise keep as Excel
8. Send form to acquisition specialist & COR for review prior to inputting invoice in WAWF / iRAPT
9. Once accepted, input invoice in WAWF / iRAPT as shown on accepted form
| 10. Ensure all required documents are either emailed to acquisition specialist or attached in WAWF |
| a. Prime and Sub-contractor payrolls to within 7 days of payment request (email) |
| b. Annotated Project Schedule showing scheduled and actual progress (email to AS and COR) |
| c. Subcontractor list (WAWF) |
| d. Progress Report or Schedule of Values (WAWF) |
IF MORE THAN 22 CLINs ON CONTRACT AN UPDATED FORM IS REQUIRED
Summary + CLIN 1_2
| APPLICATION FOR PROGRESS PAYMENT - CONSTRUCTION | | |
| TO: | DLA Distribution Acquisition Operations | Title of Project: |
| 430 Mifflin Ave, Suite 3102 | Contract Number: |
| New Cumberland, PA 17070 | Del Order Number: |
| | Invoice Number: |
| | Period Ending: |
| FROM: | (Company Name) | POC: |
| (Company Address) | Phone: |
| (City, State Zip) | Email: |
| OVERALL CONTRACT (for information purposes only) | | | | | |
| A | Original Contract Amount (Sum of CLIN lines A) | | | A | $ 7,100.00 |
| B | Net Change by Modification(s) (+/-) (Sum of CLIN lines B) | | | B | $ 220.00 |
| C | Contract Sum to Date (A+B=C) | | | C | $ 7,320.00 |
| E | Total Completed to Date (Sum of CLIN lines E) | | | D | $ 375.00 |
| F | Total Previous Payments (Sum of CLIN lines F) | | | E | $ 22.00 |
| G | Payment Request Eligible Amounts (Sum of CLIN Lines G) | | | F | $ 353.00 |
| Retainage/Witholding | | | G | 5.00% |
| CURRENT PAYMENT REQUEST | | | | $ 335.00 |
| % of Progress Schedule Completed to Date (including Mods) | | | | 5.1% |
| Total Projected Progress: | | 20.0% | Total Actual Progess: | | 5.1% |
| Certification: | | | | | |
| I herby certify, to the best of my knowledge and belief that…… (1) The amount requested are only for performance in accordance with the specifications, terms and conditions of the contract (2) Payment to subcontractors and suppliers have been made from previous payments received under the contract, 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 form a subcontractor or supplier in accordance with the terms and conditions of the contract: and (4) this certification is not to be construed as final acceptance of a subcontractor's performance. | | | | | |
| Signature: | | | Title: | | |
| FOR INVOICING IN WAWF - USE A SEPARATE SECTION FOR EACH CLIN | | | |
| A | CLIN #0001 | A | $ 100.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 110.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 5.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | $ - 0 |
| H | Current Payment Request | H | $ 4.00 |
| A | CLIN #0001 | A | $ 100.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 110.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 5.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | $ - 0 |
| H | Current Payment Request | H | $ 4.00 |
CLINs 3-7
| CLIN'S CONTINUED | | | |
| A | CLIN #0003 | A | $ 5,000.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 5,010.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 270.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | $ - |
| H | Current Payment Request | H | $ 269.00 |
| A | CLIN #0004 | A | $ 100.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 110.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 5.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | $ - |
| H | Current Payment Request | H | $ 4.00 |
| A | CLIN #0005 | A | $ 100.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 110.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 5.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | $ - |
| H | Current Payment Request | H | $ 4.00 |
| A | CLIN #0006 | A | $ 100.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 110.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 5.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | $ - |
| H | Current Payment Request | H | $ 4.00 |
| A | CLIN #0007 | A | $ 100.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 110.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 5.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | $ - |
| H | Current Payment Request | H | $ 4.00 |
CLINs 8-12
| CLIN'S CONTINUED | | | |
| A | CLIN #0008 | A | $ 100.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 110.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 5.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | |
| H | Current Payment Request | H | $ 4.00 |
| A | CLIN #0009 | A | $ 100.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 110.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 5.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | |
| H | Current Payment Request | H | $ 4.00 |
| A | CLIN #0010 | A | $ 100.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 110.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 5.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | |
| H | Current Payment Request | H | $ 4.00 |
| A | CLIN #0011 | A | $ 100.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 110.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 5.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | |
| H | Current Payment Request | H | $ 4.00 |
| A | CLIN #0012 | A | $ 100.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 110.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 5.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | |
| H | Current Payment Request | H | $ 4.00 |
CLINs 13-17
| CLIN'S CONTINUED | | | |
| A | CLIN #0013 | A | $ 100.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 110.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 5.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | |
| H | Current Payment Request | H | $ 4.00 |
| A | CLIN #0014 | A | $ 100.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 110.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 5.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | |
| H | Current Payment Request | H | $ 4.00 |
| A | CLIN #0015 | A | $ 100.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 110.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 5.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | |
| H | Current Payment Request | H | $ 4.00 |
| A | CLIN #0016 | A | $ 100.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 110.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 5.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | |
| H | Current Payment Request | H | $ 4.00 |
| A | CLIN #0017 | A | $ 100.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 110.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 5.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | |
| H | Current Payment Request | H | $ 4.00 |
CLINs 18-22
| CLIN'S CONTINUED | | | |
| A | CLIN #0018 | A | $ 100.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 110.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 5.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | |
| H | Current Payment Request | H | $ 4.00 |
| A | CLIN #0019 | A | $ 100.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 110.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 5.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | |
| H | Current Payment Request | H | $ 4.00 |
| A | CLIN #0020 | A | $ 100.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 110.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 5.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | |
| H | Current Payment Request | H | $ 4.00 |
| A | CLIN #0021 | A | $ 100.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 110.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 5.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | |
| H | Current Payment Request | H | $ 4.00 |
| A | CLIN #0022 | A | $ 100.00 |
| B | Net Change by Modification(s) (+/-) | B | $ 10.00 |
| C | Contract Sum to Date (A+B=C) | C | $ 110.00 |
| D | % of Work Completed to Date (% Value) | D | 5.4% |
| E | Value of Work Completed to Date (D*C=E) | E | $ 5.00 |
| F | Total Previous Payments | F | $ 1.00 |
| G | Retainage / Withholding | G | |
| H | Current Payment Request | H | $ 4.00 |
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