DMI-30-Form-Payment-Package-or-Final-with_Invoices_SLBE_ADA.pdf

Page 1 of 2 –DMI Payment City of Tampa – DMI Sub-(Contractors/Consultants/Suppliers) Payments

(DMI 30 FORM)

[] Partial [] Final

Contract No.: WO (if any): Contract Name: ____________________ Contractor Name: Address: ________________________________

Federal ID: Phone: Fax: Email: _________________ GC Pay Period: Payment Request/Invoice Number: City Department: ______________

Total Amount Requested for pay period: $____________ Total Contract Amount (including change orders): $___________ -Type of Ownership - S = SLBE, O = Other

Type, Federal ID

Company Name Address

Phone & Fax

Total Subcontract

Or PO Amount

Amount Paid To Date

Amount To Be Paid

For This Period

Amount Pending Previously Reported

Sub Pay Period Ending Date

(Modifying This Form or Failure to Complete and Sign May Result in Non-Compliance) Certification: I hereby certify that the above information is a true and accurate account of payments to subcontractors/consultants on this contract.

Signed: Name/Title: Date:

DMI 30 form (rev. 01/2026) Note: Detailed Instructions for completing this form are on the next page Forms must be signed and dated, or they will be considered incomplete. Failure to sign this document or return it unsigned can be cause for determining that a company is in non-compliance with Ordinance 2008-89.

Page 2 of 2 – DMI Payment Instructions for completing DMI Sub-(Contractor’s/Consultants/ Suppliers)Payment Form(DMI 30)

This form must be submitted with all invoicing or payment requests where there has been subcontracting rendered for the pay period. If applicable, after payment has been made to the subcontractor, “Waiver and Release of Lien upon Progress Payment”, “Affidavit of Contractor in Connection with Final Payment”, or an affidavit of payment must be submitted with the amount paid for the pay period.

(Modifying or omitting information from this form may result in non-compliance.)

• Contract No. This is the number assigned by the City of Tampa for the proposal.

• W.O. If the report covers a work order number (W.O. for the contract, please indicate it in that space.

• Contract Name. This is the name of the contract assigned by the City of Tampa for the bid or proposal.

• Contractor Name. The name of your business.

• Address. The physical address of your business.

• Federal ID. A number assigned to a business for tax reporting purposes.

• Phone. Telephone number to contact the business.

• Fax. Fax number for business.

• Email. Provide email address for electronic correspondence.

• Pay Period. Provide start and finish dates for the pay period. (e.g. 05/01/13 – 05/31/13)

• Payment Request/Invoice Number. Provide a sequence number for payment requests. (ex. Payment one, write 1 in the space, payment three, write 3 in the space provided.)

• City Department. The City of Tampa department to which the contract pertains.

• Total Amount Requested for the pay period. Provide all the dollars you are expecting to receive for the pay period.

• Total Contract Amount (including change orders). Provide the expected total contract amount.

• Signed/Name/Title/Date. This is your certification that the information provided on the form is accurate.

• See attached documents. Check if you have provided any additional documentation relating to the payment data. Located at the bottom middle of the form.

• Partial Payment. Check if the payment period is a partial payment, not a final payment.

• Final Payment. The check for this period is the final payment period.

The following instructions are for the information of all subcontractors used for the pay period.

• (Type) of Ownership. Indicate SLBE or Other.

• Federal ID. A number assigned to a business for tax reporting purposes.

• Company Name, Address, Phone & Fax. Provide company information for payment verification.

• Total Subcontract Amount. Provide the total amount of subcontract for the subcontractor, including change orders.

• Amount Paid to Date. Indicate all dollars paid to date for the subcontractor.

• Amount Pending, Previously Reported. Indicate any amount previously reported for which payments are pending.

• Amount To Be Paid for this Period. Provide the dollar amount requested for the pay period.

• Sub Pay Period Ending Date. Provide the date for which the subcontractor invoiced for the work performed.

If any additional information is required or you have any questions, you may call the Office of Equal Business Opportunity at (813) 274-5522.