Contractor Invoice Form.pdf

CONTRACTORS REQUEST FOR PROGRESS PAYMENT / INVOICE

TO: Department of Veterans Affairs FROM:

Durham VAMC 508 Fulton Road Durham, NC 27705-3875

Contract #: ____________________________ Project Title:

Task Order #: __________________________ Project Number:

P.O. #: ________________________________ Progress Payment/Invoice #:

COR Name: Progress Payment/Invoice Date:

CO Name:

STATEMENT OF COSTS UNDER THIS CONTRACT THROUGH: ___________________

(DATE)

A. ORIGINAL CONTRACT PRICE: $________________________________

B. MODIFICATIONS: $________________________________

C. SUB-TOTAL (A+B) $________________________________

D. ACTUAL % COMPLETE CUMMULATIVE – ____% $________________________________

E. LESS PREVIOUS PAYMENTS $________________________________

F SUB-TOTAL (D-E) $________________________________

G. LESS RETAINAGE (If applicable) ________% $________________________________

H. TOTAL DUE THIS PAY PERIOD (F-G) $________________________________

CERTIFICATION:

I hereby certify, to the best of my knowledge and belief, that:

(1) The amounts requested are only for performance in accordance with specifications, terms and conditions of the contract;

(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 subcontractor agreements and the requirements of Chapter 39 of Title 31, United States Code; and

(3) This request for progress payment 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.

Name & Title of Contractor Representative Signature Date

I approve the payment of this estimate in the amount of $ and certify that the articles and/or services represented hereon have been received and/or rendered in accordance with the terms of the above-referenced contract.

Name of Contracting Officer’s Representative (COR) Signature Date

Name of Contracting Officer / Contract Specialist Signature Date