1510-010_Certificate_for_Contract_Payment_-_Construction.doc

SEQ CHAPTER \h \r 1Form 1510-10

UNITED STATES

DEPARTMENT OF THE INTERIOR

BUREAU OF LAND MANAGEMENT

CERTIFICATE FOR CONTRACT PAYMENT/INVOICE

Date

Contract Number

Delivery/Task Order

To: Contracting Officer

Contractor Name

Contractor Address (include zip code)

Contract Title

Contractor Phone (include area code)

I CERTIFY That the total work listed below constitutes the accomplishments completed by the contractor to (date) 00/00/0000; that the contractor performed the work in accordance with the specifications and drawings; and that the contractor has complied with the labor and other provisions of the contract. Accordingly payment is due the contractor for the amounts shown below.

"Notice to Proceed" effective date:

Received Date 00/00/0000 Acceptance Date 00/00/0000

The quantities and total values shown below are cumulative to date. This payment represents

( Partial Payment no. ( Progressive Payment no. ( Final Payment

ITEM

NO.

ESTIMATED

QUANTITY*

PRICE

AMOUNT

PER-

CENT

QUANTITY

Cumulative Total

Previous Invoice(s) Previous Invoice(s)

Retain % or $ or

CO Initials _____________

FOR CERTIFYING OFFICERS ONLY

Other deductions

Net payment due

Date transmitted to Treasury for payment

*As of date each payment certificate is prepared (Certification on reverse)

CERTIFICATION OF PROGRESS PAYMENTS

UNDER FIXED-PRICE CONSTRUCTION CONTRACTS

Contract Number:

Contractor’s Name:

Payee’s Name and Address:

Discount Terms:

I HEREBY CERTIFY, to the best of my knowledge and belief, that:

(1) The amounts requested are only for performance in accordance with the specifications, terms and conditions of the contract;

(2) Payments to subcontractors and suppliers have been made from previous payments received under the contract, and timely payments will be made from the proceeds of the payment covered by this certification, in accordance with subcontract agreements and the requirements of chapter 39 of Title 31, United States Code;

(3) This request for progress payments does not include any amounts which the prime contractor intends to withhold or retain from a subcontractor or supplier in accordance with the terms and conditions of the subcontract; and

(4) This certification is not to be construed as final acceptance of a subcontractor’s performance.

(Name)

(Title)

(Date)