B01 Section J Attachment 2 - Application for Payment Form.xls
XLS spreadsheet 125 KB Posted
- Attached to
- Albuquerque SFC MATOC Federal contract opportunity
- Solicitation number
- 75H70120R00011
About this file
This document contains an application for payment form and details of a federal contract opportunity for sanitation facilities construction services. The indefinite delivery, indefinite quantity multiple award task order contract will have a one-year base period and four optional one-year extensions and be awarded by the Indian Health Service to between three to five contractors. Work will primarily be performed in the Albuquerque region but may occur nationwide. Contractors will submit payment applications using the provided form detailing original contract amounts, modifications, work completed, retention amounts, and payments to date. The Indian Health Service seeks sanitation facilities construction services through task orders issued against this multiple award contract.
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Text version
Application for Payment
| Contractor's Application for Payment | ||||
| Progress Payment / Invoice #: | Date: | |||
| Contractor Name: | Contract Number: | |||
| Contractor Address: | Task/Delivery Order Number: | |||
| Contractor TIN / DUNS: | Project Title: |
Location:
| To be completed by the Contractor: | To be completed by the Government: | ||||
| 1. | Original Contract Amount (Part A Column E) | $ - 0 | (Enter amount from item 10) | $ - 0 | |
| 2. | Net Change by Modifications (Part B Column F) | $ - 0 | |||
| 3. | Adjusted Contract Amount to Date (1 + 2) | $ - 0 | 11. | Amount retained by Government per FAR 52.232-5 (e) | $ - 0 |
| 4. | Original Contract Work Complete (Part A Column J) | $ - 0 | Explanation of withheld amount: | ||
| 5. | Modification Work Complete (Part B Column J) | $ - 0 | |||
| $ - 0 | |||||
| 6. | Total Progress (4 + 5) | $ - 0 | |||
| 7. | Subcontract Retention (Part C Column G) | $ - 0 | |||
| 8. | Net Earned Progress (6 - 7) | $ - 0 | 12. | Balance Due This Pay Request (10 - 11) | $ - 0 |
| 9. | Previous Payments | $ - 0 | |||
| 10. | Net Payment Requested (8 - 9) | $ - 0 | Contracting Officer Representative (COR) Certification: | ||
| I certify that all work and/or materials under the contract have been inspected by the Government and that the work and/or materials have been performed and/or supplied in full accordance with the requirements of the contract. I recommend that the Contractor should be paid the amount requested and/or adjusted amount noted on this form. | |||||
| Contractor Certification Per FAR 52.232-5 (c) | |||||
| Per FAR 52.232-5(c) the Contractor shall furnish the following certification, or payment shall not be made: (However, if the Contractor elects to delete paragraph (c)(4) from thecertification, the certification is still acceptable.) |
I hereby certify, to the best of my knowledge and belief, that--
(1) The amounts requested are only for performance in accordance with the specifications, terms, and conditions of the contract;
(2) Payments 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 from a subcontractor or supplier in accordance with the terms and conditions of the subcontract; and
(4) This certification is not to be construed as final acceptance of a subcontractor's performance.
| Contracting Officer Representative (COR) | ||||||
| (Printed Name / Signature) | Date Proper Invoice Received | |||||
| Approved By: | ||||||
| Division of Facilities Engineering, Design & Construction | ||||||
| (Printed Name / Signature) | Date | |||||
| Printed Name / Signature / Title | Date | Contracting Officer (Printed Name / Signature) | Date | |||
| Contractor Must Answer: | For Government Administrative Use Only | |||||
| Small Business: | Y / N | Prompt Payment Effective Date: | ||||
| Tripartite / 3rd Party Agreement: | Y / N | Prompt Payment Terms: | ||||
| Final Payment: | Y / N | |||||
| MUST Include Release of Claims (ROC) with Final Payments |
Indian Health Service
DEPARTMENT OF HEALTH & HUMAN SERVICES
Pay Request Part A (orig)
| Progress Payment / Invoice Number: | Date: | |||||||||
| Name of Contractor | Contract Number | |||||||||
| Part A: Completed Work Under Original Contract | ||||||||||
| A | B | C | D | E | F | G | H | I | J | K |
| Item No. | Description of Item | Quantity | Unit of Issue | Unit Cost | Total Cost | Percentage or Estimated Amounts Installed | Payments | Total to Date | ||
| Previous | This Period | Previous | This Period | |||||||
| 1 | General Conditions | |||||||||
| 2 | Mobilization | |||||||||
| 3 | Demobilization - Closeout | |||||||||
| 4 | Additional Line Items 4 through _____ | |||||||||
| Contractors G&L Insurance & Bonds | ||||||||||
| TERO | ||||||||||
| TOTAL CONTRACT AMOUNT | ||||||||||
| Contractor: _______________________________________________________ | ___________ | |||||||||
| Signature/Title | Date | |||||||||
| Government Approval: ______________________________________________ | ___________ | |||||||||
| Project Officer | Date | |||||||||
| ______________________________________________ | ___________ | |||||||||
| Contracting Officer | Date |
Indian Health Service
DEPARTMENT OF HEALTH & HUMAN SERVICES
Pay Request Part B(mods)
| Progress Payment / Invoice Number: | Date: | ||||||||
| Name of Contractor | Contract Number | ||||||||
| Part B: Contract Modifications | |||||||||
| A | B | C | D | E | F | G | H | I | J |
| Mod No. | Date | Description of Item | Quantity & Unit of Issue | Unit Cost | Total Cost | Completed | Stored Materials | Total Completed & Stored | |
| Previous | This Period | ||||||||
| TOTALS |
Indian Health Service
DEPARTMENT OF HEALTH & HUMAN SERVICES
Pay Request Part C (subs)
| Progress Payment / Invoice Number: | Date: | ||||||
| Name of Contractor | Contract Number | ||||||
| Part C: Payments to Subcontractors | |||||||
| A | B | C | D | E | F | G | H |
| Item No. | Subcontractor Name | Subcontract Amount Including Changes | Progress | Retention in Accordance with Subcontract Terms | Net Due to Subcontractor Through This Application for Payment | ||
| Previous | This Period | Total | |||||
| TOTALS |
Indian Health Service
DEPARTMENT OF HEALTH & HUMAN SERVICES
File details come from the government source that posted it. Updated .