(HUD-51001) Periodic Payments.pdf

Periodic Estimate for Partial Payment

U.S. Department of Housing OMB Approval No. 2577-0157 (exp. 11/30/2023) and Urban Development

Office of Public and Indian Housing

Submit original and one copy to the Public Housing Agency.

Complete instructions are on the back of this form.

Public reporting burden for this collection of information is estimated to average 3.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. HUD may not conduct or sponsor , and an applicant is not required to respond to a collection of information unless it displays a currently valid OMB control number. This information is collected under the authority of Section 6(c) of the U.S Housing Act of l937 and HUD regulations. HAs are responsible for contract administration to ensure that the work for project development is done in accordance with State laws and HUD requirements. The contractor/subcontractor reports provide details and summaries on payments, change orders, and schedule of materials stored for the project The information will be used to ensure that the total development cost s, identified in the ACC, are kept as low as possible and consistent with HUD construction requirements. Responses to the collection are necessary to obtain a benefit. The information requested does not lend itself to confidentiality.

Name of Public Housing Agency Periodic Estimate Number Period

From (mm/dd/yyyy) To (mm/dd/yyyy)

Item Number (1)

Description of Item (2)

Completed to Date (3)

Value of Contract Work Completed to Date (Transfer this total to line 5 on back of this sheet) $

Previous editions are obsolete form HUD-51001 (1/2014)

Location of Project Project Number

Name of Contractor Contract Number

Instructions

Headings. Enter all identifying data required. Periodic estimates must be numbered in sequence beginning with the number 1.

Certifications. The certification of the contractor includes the analysis of amounts used to determine the net balance due. In the first paragraph, enter the name of the Public Housing Agency, the contractor, and the date of the contract. Enter the calculations used in arriving at the "Balance Due This Payment" on lines 1 through 16.

Columns 1 and 2. The"Item Number"and "Description of Item" must correspond to the number and descriptive title assigned to each principal division of work in the "Schedule of Amounts for Contract Payments", form HUD-51000. Enter the contractor's name and signature in the certification following line 16.

Column 3. Enter the accumulated value of each principal division of work completed as of the closing date of the periodic estimate. Enter the total in the space provided.

The latter portion of this certification relating to payment of legal rates of wages, is required by the contract before any payment may be made.

However, if the contractor does not choose to certify on behalf of his/her subcontractors to wage payments made by them, he/she may modify the language to cover only himself /herself and attach a list of all subcontractors who employed labor on the site during the period covered by the Periodic Estimate, together with the individual certifications of each.

Certification of the Contractor or Duly Authorized Representative

According to the best of my knowledge and belief, I certify that all items and amounts shown on the other side of this form are correct; that all work has been performed and material supplied in full accordance with the items and conditions of the contract between the (name of owner) and (contractor) dated (mm/dd/yyyy) , and duly authorized deviations, substitutions, alterations, and additions; that the following is a true and correct statement of the Contract Account up to and including the last day of the period covered by this estimate, and that no part of the "Balance Due

10. Net amount earned to date (line 8 less line 9)

11. Less: Previously earned (line 10, last Periodic Estimate)

12. Net amount due, work in place (line 10 less line 11)

Value of Materials Properly Stored

13. At close of this period (from form HUD-51004)

14. Less: Allowed last period

15. Increase (decrease) from amount allowed last period

This Payment" has been received.

1. Original Contract Amount $

Approved Change Orders:

2. Additions (Total from Col. 3, form HUD-51002) $

3. Deductions (Total from Col. 5, form HUD-51002) $ (net) $

4. Current Adjusted Contract Amount (line 1 plus or minus net) $

Computation of Balance Due this Payment

5. Value of Original Contract work completed to date (from other side of this form) $

Completed Under Approved Change Orders

6. Additions (from Col. 4, form HUD-51002)

7. Deductions (from Col.5, form HUD-51002)

$ (net) $

8. Total Value of Work in Place (line 5 plus or minus net line 7) $

9. Less: Retainage, % $

16. Balance Due This Payment

I further certify that all just and lawful bills against the undersigned and his/her subcontractors for labor, material, and equipment employed in the performance of this contract have been paid in full in accordance with the terms and conditions of this contract, and that the undersigned and his/her subcontractors have

I certify the information on this form and in any accompanying documentation is true and accurate. I acknowledge making, presenting, or submitting a false, fictitious, or fraudulent statement, rep resentation, or certification may result in criminal, civil, and/or administrative sanctions, including fines, penalties, and confinement for up to 5 years, (18 U.S.C. §§ 287, 1001 and 31 U.S.C. §3729 complied with, or that there is an honest dispute with respect to, the labor provisions of this contract.

Name of Contractor Signature of Authorized Representative Title Date (mm/dd/yyyy)

Certificate of Authorized Project Representative and of Contracting Officer

Each of us certifies that he/she has checked and verified this Periodic Estimate No. ; that to the best of his/her knowledge and belief it is a true statement of the value of work performed and material supplied by the contractor; that all work and material included in this estimate has been inspected by him/her or by his/her authorized assistants; and that such work has been performed or supplied in full accordance with the drawings and specifications, all applicable accessibility requirements (including Section 504 and Title II of the Americans with Disabilities Act; and the Fair Housing Act and Title III of the Americans with Disa bilities Act, if applicable),the terms and conditions of the contract, and duly authorized deviations, substitutions, alterations, and additions, all of which have been duly approved.

We, therefore, approve as the "Balance Due this Payment" the amount of $

Authorized Project Representative Date (mm/dd/yyyy) Contracting Officer Date (mm/dd/yyyy)

Previous editions are obsolete form HUD-51001 (1/2014)