Attachment IV - ARS-372.pdf

PDF 56 KB Posted

Attached to
Boiler Replacement Federal contract opportunity
Solicitation number
12805B20Q0161
Issued by
Department of Agriculture Agricultural Research Service Field Research Implementation and Information Delivery Plains Area

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Attachment I - DBA Wage Rates.pdf PDF
Attachment V - Bond Forms.pdf PDF
Attachment VI - FAR Deviation Accelerated Payments to Small Business.pdf PDF
Attachment II - Replace Boiler SOW 20200806.pdf PDF
Attachment III - ARS-371.pdf PDF
RFQ - 12805B20Q0161.pdf PDF
Show all 12

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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 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 contractual 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/OCIO/ADB.

% retainage

ffSignImage01:
ffSignImage02:
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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.:
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Contractor's request for payment transmittal. Enter contract number.:
Partial payment number.:
Project.:
Requisition number.:
Location.:
Description. Line 1.:
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Click to return to catalog:
Click to save form:
Save As:
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BtnNam:
Name of record:
UserName: Michael A Douglas
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fscSubmitURL: https://reeforms.ars.usda.gov/REEForms/ffSubmitXFA.asp?id=A40DC209CE8CA4DFA31AE4AECA864C271708B758333434B0F1667762E3FB770CBDD0AA8B3A2E29CA00D08F8B92960165407DBF3B8F8BC3F310F2BA82CCA645832C6EDF5682A19AB7
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SignatureField: arsnet-michael.douglas
CLICK TO SIGN FORM:
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CLICK TO CLEAR SIGNATURE:
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SIGNATURE AND TITLE:
SIGNATURE AND TITLE:
CLICK TO CLEAR SIGNATURE:
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SIGNATURE AND TITLE:
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ffSignLockFields03:
ffSignInfo03:
ffSignDate03:
SIGNATURE AND TITLE:
SIGNATURE AND TITLE:

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