FORM_-_3_Personal-Professional_Contract_-_Monthly_Sub-consultant_Payment_and_Utilization_Report_.pdf

442 KB Posted

Attached to
Public Works Asset Management Replacement
Solicitation number
26-062
Issued by
Washington County, Barlow City, Oregon

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This is a Monthly Subcontractor Payment and Utilization Report form designed for professional service contracts, used to track subcontractor payments and certify business utilization on state and local projects. The form is completed monthly by prime contractors and requires identification of all subcontractors listed in the original bid plan, including their certification status and payment information for each reporting period. Contractors must receive written authorization from the Purchasing Agent before replacing, substituting, or adding any subcontractor to the project.

The form requires contractors to report the original award amount for each subcontractor, any amended award amounts if applicable, and the total amount paid to each subcontractor during the current pay period only. Subcontractors must be evaluated for minority-owned business (MBE), women-owned business (WBE), service-disabled veteran-owned (SDV), emerging small business (ESB), and disadvantaged business enterprise (DBE/ACDBE) certifications, with corresponding checkboxes for each designation. The authorized contractor representative must certify that all listed firms have been utilized in the amounts represented and that the information provided is complete and accurate, with signature, date, and printed name required for validation of the monthly utilization report.

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FORM_-_3_Personal-Professional_Contract_-_Monthly_Sub-consultant_Payment_and_Utilization_Report_.pdf PDF
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Form_1._Personal_Professional_Sub-consultant_Disclosure_Form.pdf PDF

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PROGRAM: FORM 3

PROFESSIONAL SERVICE - MONTHLY SUBCONTRACTOR PAYMENT AND UTILIZATION REPORT

Date Submitted: ______________________________________ Report for FY: __________________ Month: ____________

Project Name: ________________________________________________________________________ Contract Number: _________________________

Prime Consultant: _____________________________________________________________________ Total Contract Amt.: ______________________

Progress Report No.: __________________________________________________________________ Final Progress Report? ☐ Yes ☐ No

* Before replacing, substituting, or adding any subcontractor, Contractor must receive written authorization from the Purchasing Agent.

** ESB: Emerging Small Business; MBE: Minority-owned Business; WBE: Women-Owned Business; SDV: Service-Disabled Veteran-Owned; DBE & ACDBE: Disadvantaged Business Enterprise

BY SIGNING BELOW, I HEREBY CERTIFY THAT THE BUSINESS HAS UTILIZED THE ABOVE LISTED FIRMS IN THE AMOUNTS REPRESENTED ABOVE AND THAT

THE INFORMATION CONTAINED HEREIN IS COMPLETE AND ACCURATE.

Authorized Signature of Contractor: __________________________________________________________ Date: __________________

Printed Name of Signatory: _________________________________________________________________

NAME OF SUBCONTRACTOR*

(INCLUDE ALL LISTED ON BID PLAN)

COBID

Certified

TYPE OF CERTIFICATION**

(Check all that apply) ORIGINAL AWARD

AMOUNT

AMENDED AWARD

AMOUNT

(IF APPLICABLE)

TOTAL AMOUNT

PAID

THIS PAY PERIOD ONLY

MBE WBE SDV ESB

DBE &

ACDBE

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

☐ Yes ☐ No

Date Submitted:
Report for FY:
Month:
Project Name:
Contract Number:
Prime Consultant:
Total Contract Amt:
Progress Report No:
Final Progress Report: Off
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow1:
undefined: Off
MBEYes No:
WBEYes No:
SDVYes No:
ESBYes No:
DBE ACDBEYes No:
ORIGINAL AWARD AMOUNTYes No:
AMENDED AWARD AMOUNT IF APPLICABLEYes No:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No:
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow2:
undefined_2: Off
MBEYes No_2:
WBEYes No_2:
SDVYes No_2:
ESBYes No_2:
DBE ACDBEYes No_2:
ORIGINAL AWARD AMOUNTYes No_2:
AMENDED AWARD AMOUNT IF APPLICABLEYes No_2:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No_2:
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow3:
undefined_3: Off
MBEYes No_3:
WBEYes No_3:
SDVYes No_3:
ESBYes No_3:
DBE ACDBEYes No_3:
ORIGINAL AWARD AMOUNTYes No_3:
AMENDED AWARD AMOUNT IF APPLICABLEYes No_3:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No_3:
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow4:
undefined_4: Off
MBEYes No_4:
WBEYes No_4:
SDVYes No_4:
ESBYes No_4:
DBE ACDBEYes No_4:
ORIGINAL AWARD AMOUNTYes No_4:
AMENDED AWARD AMOUNT IF APPLICABLEYes No_4:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No_4:
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow5:
undefined_5: Off
MBEYes No_5:
WBEYes No_5:
SDVYes No_5:
ESBYes No_5:
DBE ACDBEYes No_5:
ORIGINAL AWARD AMOUNTYes No_5:
AMENDED AWARD AMOUNT IF APPLICABLEYes No_5:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No_5:
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow6:
undefined_6: Off
MBEYes No_6:
WBEYes No_6:
SDVYes No_6:
ESBYes No_6:
DBE ACDBEYes No_6:
ORIGINAL AWARD AMOUNTYes No_6:
AMENDED AWARD AMOUNT IF APPLICABLEYes No_6:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No_6:
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow7:
undefined_7: Off
MBEYes No_7:
WBEYes No_7:
SDVYes No_7:
ESBYes No_7:
DBE ACDBEYes No_7:
ORIGINAL AWARD AMOUNTYes No_7:
AMENDED AWARD AMOUNT IF APPLICABLEYes No_7:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No_7:
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow8:
undefined_8: Off
MBEYes No_8:
WBEYes No_8:
SDVYes No_8:
ESBYes No_8:
DBE ACDBEYes No_8:
ORIGINAL AWARD AMOUNTYes No_8:
AMENDED AWARD AMOUNT IF APPLICABLEYes No_8:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No_8:
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow9:
undefined_9: Off
MBEYes No_9:
WBEYes No_9:
SDVYes No_9:
ESBYes No_9:
DBE ACDBEYes No_9:
ORIGINAL AWARD AMOUNTYes No_9:
AMENDED AWARD AMOUNT IF APPLICABLEYes No_9:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No_9:
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow10:
undefined_10: Off
MBEYes No_10:
WBEYes No_10:
SDVYes No_10:
ESBYes No_10:
DBE ACDBEYes No_10:
ORIGINAL AWARD AMOUNTYes No_10:
AMENDED AWARD AMOUNT IF APPLICABLEYes No_10:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No_10:
NAME OF SUBCONTRACTOR INCLUDE ALL LISTED ON BID PLANRow11:
undefined_11: Off
MBEYes No_11:
WBEYes No_11:
SDVYes No_11:
ESBYes No_11:
DBE ACDBEYes No_11:
ORIGINAL AWARD AMOUNTYes No_11:
AMENDED AWARD AMOUNT IF APPLICABLEYes No_11:
TOTAL AMOUNT PAID THIS PAY PERIOD ONLYYes No_11:
Date:
Printed Name of Signatory:

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