Contractor Invoice Form.pdf

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Attached to
4130--Campus Energy Management System Pre-Solicitation Notice
Solicitation number
36C24626B0018
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This is a Contractors Request for Progress Payment/Invoice form used by the Department of Veterans Affairs (specifically Salisbury VAMC in Salisbury, North Carolina) to process contractor invoices for work performed under federal contracts. The form is a template designed to standardize payment requests across VA contracting activities.

The form requires contractors to document cumulative costs by listing the original contract price, any modifications, actual percentage of work completed, previous payments received, and applicable retainage amounts to calculate the total due in the current pay period. Contractors must certify that amounts requested correspond to contract specifications and terms, that all subcontractor and supplier payments from previous invoices have been made timely per federal requirements under 31 U.S.C. Chapter 39, and that no improper withholdings from subcontractors are included. The form requires three separate signatures: the contractor representative, the Contracting Officer's Representative (COR), and the Contracting Officer or Contract Specialist, each attesting to the accuracy and approval of the payment request. The form includes fields for contract number, task order number, purchase order number, project title, and invoice tracking information.

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File Type Posted
Bid Documents Submission - Drawings.pdf PDF
659-22-100_QAQC Bid Docs - Specifications.pdf PDF
36C24626B0018_2_.pdf PDF

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CONTRACTORS REQUEST FOR PROGRESS PAYMENT / INVOICE

TO: Department of Veterans Affairs FROM:

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

Salisbury VAMC 1601 Brenner Ave Salisbury NC 28144

1- 509-CSI-509 - VIR Suite_Invoice_COR Approved
Contractor Request for Progress Payment-Invoice 50143 signed
FROM 1:
FROM 2:
FROM 3:
FROM 4:
Contract:
Project Title:
Task Order:
Project Number:
PO:
Progress PaymentInvoice:
COR Name:
Progress PaymentInvoice Date:
CO Name:
STATEMENT OF COSTS UNDER THIS CONTRACT THROUGH:
undefined:
undefined_2: 0.00
undefined_3:
ACTUAL COMPLETE CUMMULATIVE:
undefined_4:
undefined_5: 0,00
undefined_6:
LESS RETAINAGE If applicable:
undefined_7: 0.00
undefined_8:
Name Title of Contractor Representative:
Signature:
Date:
I approve the payment of this estimate in the amount of:
Name of Contracting Officers Representative COR:
Signature_2:
Date_2:
Name of Contracting Officer Contract Specialist:
Signature_3:
Date_3:

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