B08d Invoice Payment Request.pdf

INVOICE/Payment Request Date Prepared:

Sheet of INVOICE/Payment Number:

Contract Number: Required Completion Date: Prompt Payment Discount:

% if paid in days after

Contractor’s Name and Address:

Description and Location of Work:

Accounting and Appropriation Data:

Bid Item

Description from Bid Price Schedule

Total Contract Amounts Actual Amount Complete To-Date

UNIT QTY UNIT

PRICE AMOUNT QTY AMOUNT

Total: Total:

REMARKS: (“Contractor’s Release” statement MUST be a. Previous deductions other than retained percentage completed before FINAL PAYMENT under this contract will be made.) Attach Subcontract Payment Data for Progress b. Previous retained percentage

Payments as required by Payments Clause, FAR 52.232-5.

c. Previous payments

d. Previous earnings (a + b + c)

e. Earnings this period (Total “To-date” – d)

f. Less retained percentage

g. Less deduction other than retained percentage

h. Total deductions this period (f + g)

NPS Actions: i. Amount due contractor this period (e + h)

Admin Compliance Checked: Date: j. Plus previous retained

k. Total amount due (i+ j)

Received Date: Accepted Date: RECAPITULATION: (sum of retained, paid, & balance = total contract amount)

TOTAL RETAINED: (a + b + h - j):

Contracting Officer Approval: Date Signed: TOTAL PAID (c + k):

BALANCE remaining after this payment:

COR Approval: Date Signed:

COMPLETE IF PROGRESS PAYMENTS ARE MADE UNDER THE CONTRACT:

In accordance with the clause at FAR 52.232-5, Payments Under Fixed Price Construction Contracts, 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 the 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; and

(3) This request for Progress Payments does not include any amounts that the Prime Contractor intends to withhold or retain from a subcontractor or supplier in accordance with the terms and conditions of the contract.

(4) This certification is not to be construed as final acceptance of a subcontractor’s performance. (If applicable)

NAME: TITLE:

(Print/Type Name) (Print/Type Title)

SIGNATURE: DATE:

Subcontractor Payment Information Date Prepared: Sheet of INVOICE/Payment Number:

Contract Number: Required Completion Date:

Name of Subcontractor: Subcontractor Address:

Amount of Subcontract:

Amount Performed This Request:

Total Amount Previously Paid:

Name of Subcontractor: Subcontractor Address:

Total Amount Previously Paid:

Name of Subcontractor: Subcontractor Address:

Total Amount Previously Paid:

Name of Subcontractor: Subcontractor Address:

Total Amount Previously Paid:

Name of Subcontractor: Subcontractor Address:

Total Amount Previously Paid:

Subcontractor Payment Information