RFP 283-20-0556 Attachment 3_Voucher Review Sheet.docx
DOCX document 23 KB Posted
- Attached to
- Behavioral Health Services Information System (BHSIS) - Small Business Sources Sought Federal contract opportunity
- Solicitation number
- 283-20-0556
About this file
This document contains a voucher review sheet template for the Behavioral Health Services Information System (BHSIS) contract. The template is to be used by the Contracting Officer's Representative to review vouchers submitted by the contractor for costs incurred under the cost reimbursement contract. The voucher review sheet requests confirmation that costs are reasonable and commensurate with efforts, deliverables are acceptable, and payment is recommended. Space is also provided to note any questioned costs. Upon approval by the COR and contracting officer, the voucher will be paid by the Program Support Center accounting office to the contractor.
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Text version
RFP No. 283-20-0556 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: ____________________, 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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