RFP 270-22-0573 Attachment 3 Voucher Review Sheet.pdf
PDF 139 KB Posted
- Attached to
- National Center on Substance Abuse and Child Welfare (NCSACW) Technical Assistance and Training
- Solicitation number
- 270-22-0573
About this file
This document contains a voucher review sheet template for a cost reimbursement contract. The template is to be used by the contracting officer's representative to review vouchers submitted by the contractor for period covered, confirm deliverables have been received and are acceptable, and recommend approval or question of costs claimed. It includes fields for contract and reference numbers, contractor information, dates received and due, amounts claimed and recommended for payment, as well as a signature line for the COR to sign off on recommended payment.
This federal contract opportunity is a solicitation seeking proposals for the National Center on Substance Abuse and Child Welfare Technical Assistance and Training contract. Services required include technical assistance, training, resource development, information dissemination, and website support and maintenance. The purpose is to improve systems and practices for families with substance use disorders or co-occurring mental health disorders involved with or at risk of involvement with the child welfare and family court systems. The Department of Health and Human Services Substance Abuse and Mental Health Services Administration is the contracting agency.
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Text version
RFP No. 270-22-0573 Attachment 3: Voucher Review Sheet
VOUCHER REVIEW SHEET
Contract No.: Ref. No.
Contractor:
DUNS:
Received in DCM/OFR: X Cost Reimbursement Today’s Date: Fixed Price Date Due in DCM: IQC Work Order Date Due in PSC/DFS: Letter of Credit Contract Financing (N/A if letter of credit)
To: _______________, Contracting Officer Representative (COR)
From: _Carla Carter_, Division of Contracts Management, OFR, SAMHSA, 5600 Fishers Lane
Subject: Voucher No. ________________
Period Covered: __________________________________
Contractor Point of Contract: ______________________ Telephone: _______________ Email: ________________
COR:
Please review the Voucher, answer the following question and return to DCM by the date shown above.
YES NO
1. Are costs commensurate with efforts expended? _____ _____
2. Are all elements of cost reasonable, in support of contract performance and consistent with amounts negotiated?
3. Have deliverables received during the period been timely and acceptable?
4. Do you recommend payment be made as claimed? _____ _____
5. Do you question any costs claimed? If yes, explain below.
(ATTACH ADDITIONAL SHEET OF PAPER IF NEEDED.)
COR sign and date here: ________________________________________ Date: __________________
To: Program Support Center PAY THIS AMOUNT: _______________________
DFO Accounting Operations AMOUNT CLAIMED: _______________________
AMOUNT TO BE SUSPENDED FROM
PAYMENT:
In accordance with the Prompt Payment Provisions (Subsection (b)(4)), INTEREST [ ] IS / [ ] IS NOT payable under this Invoice or “Contract Financing Payment.” TO BE PAID NO LATER THAN _____________________.
* NOTE: THIS INVOICE/VOUCHER IS APPROVED FOR PROVISIONAL PAYMENT ONLY. All payments are subject to change pending final audit.
Reason for Suspension:
Approved for payment: ______________________________________________ Date: __________________ Contract Specialist
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