012900-form.pdf

Progress Payment Request for Fixed Price Construction Contracts

Invoice Number: _________________Invoice Submitted for Period Ending:____________________

Contract Number: DAHA11-________-________-________ Delivery/Task Order Number: ___________ Project Description:_____________________________________________________________________ Prompt Payment Discount Terms__________________________________________________________

Remit To: (Must be the same as that in the contract or in a proper notice of assignment.)

Name:_________________________________ Address________________________________

Person to be notified if invoice is defective:

Name:_________________________________ Address________________________________ Phone:_________________________________

A. Current Contract Value: (including all modifications) B. Percent Complete:

C. Dollar Value of Completed Work:

(A x B = C) D. Total of Previous Payments:

E. Dollar Value of Completed Work, less the Total of Previous Payments: (C-D = E) F. Percent Behind Schedule:

(E/Contract Amount = F) G. Retainage (E x F = G)

H. Subtotal (E-G=H)

I. Withholding:

J. Total Amount Requested for Payment (H-I=J):

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 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 payment 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.

(Signature) (Printed/Typed Name) (Title) (Date)

This area is for Government use only.

Approved for the amount of $____________________________ Payment # ___________________________

Disapproved

(Contracting Officer’s Signature) (Date) Contracting Officer’s Printed Name

This payment is for Small Disadvantaged Business (SDB) Invoice Received at Contracting Office.