Att 07 FMD_70.pdf

FTC-FAC-70 (9/01)

Contract No. Invoice No. Invoice Date

Delivery Order No. Work Order No.

Total Contract Amount Through Change Order No. Dated

Value of Work Completed

Total of Prior Invoices

Amount of this Invoice

Signature and Title

GOVERNMENT CERTIFICATION OF INVOICE Date

FROM: Contracting Officer's Technical Representative (COTR) THRU: (1) Chief, Design-Construction Branch (FMD/D-CB)

(2) Contracting Officer (PRO/CCB) TO: Budget and Finance Division (BFD/FIN)

CONTRACT WORK CERTIFIED COMPLETE $

LESS: Retention $

Previous Payments $

Other (Deductions) $

Liquid Damages @ $ /day X Days = $

AMOUNT CERTIFIED FOR PAYMENT $

Remarks:

Evaluated

COTR/PM (FMD) Contracting Officer (PRO/CCB) Reviewed

Chief, Design/Construction Branch (FMD)

CONTRACTOR MUST ALSO COMPLETE CERTIFICATION ON REVERSE OR PAYMENT WILL NOT BE MADE

For FLETC Use Only

OFFICIAL DATE OF RECEIPT BY GOVERNMENT

Contractor's Name and Address (As shown on Contract)

CONSTRUCTION CONTRACTOR'S

INVOICE

(Authorized Contractor Representative)

By

Payment Approved

By:By:

Front