J-0200000-04 INVOICE FORM.pdf

NAVFAC 7300/30 NAVAL FACILITIES ENGINEERING COMMAND

(Rev 2/01)

DUNS NO: ________________

1. CONTRACTOR'S INVOICE CAGE CODE NO: ________________

From:

POC/Telephone/email for this invoice:

To:

Below is a Statement of Performance under Contract N40085- Task Order:

for at

The enclosure provides breakdown of this statement of performance.

A. Total value of contract/task order through change B. Percentage of performance complete C. Value of completed performance D. Less total of prior payments E. Amount of this invoice

Signature and Title:

Date:

2. FIRST ENDORSEMENT Receipt and Acceptance Certification From:

To:

1. Payment is recommended as follows:

A. Amount of work completed to (date) B. Less:

Retention

C. Subtotal D. Less previous payments E. Certified amount for payment # Final on TO # F. Elapsed contract time (if applicable)

G. Responsible Certifying UIC H. Invoice Receipt Date I. Material/Services Receipt Date J. Material/Services Acceptance Date K. Date forwarded to paying office L. I certify this amount is correct and payment is recommended.

Signature: Date:

Signature of Authorized Representative

Name and Title (typed):

Phone and address:

3. PROMPT PAYMENT CERTIFICATION

I certify that the accounting data provided is accurate, funds have been obligated in appropriate accouting system and changes have been applied to the apprpriate accounting classification reference number (ACRN), available funds have been decremented for the amount approved for disbursement and will not be de-obligated and the aboave invoice is correct and proper for payment.

Signature: Date:

Signature of Authorized Representative

Name and Title (typed):

Phone and address:

Line(s) of accounting to be used for this invoice (include appropriate Line Item # (CLIN, SLIN, or ACRN, etc)

Other Deductions:

Invoice Date Invoice Number

Signature of Authorized Representative

Contract Specialist:

Attachment J-0200000-04 Invoice Form

Sheet1