1. DATE
PAYMENT ESTIMATE - CONTRACT PERFORMANCE
For use of this form, see ER 37-2-10 and 37-345-10.
SHEET
of
2. CONTRACTOR AND ADDRESS
3. CONTRACT NO.
4. DISTRICT
5. DESCRIPTION OF WORK
6. APPROPRIATION AND PROJECT
7. REQUIRED COMPLETION
DATE
8. LOCATION
9. PERIOD COVERED BY THIS ESTIMATE
10. JOB ORDER NO. 11. ESTIMATE NO.
FROM
THRU
CONTRACT
TOTAL TO DATE
ITEM
QUANTITY AND
UNIT
QUANTITY AND
NO.
DESCRIPTION
UNIT
PRICE
AMOUNT
UNIT
AMOUNT
a
b
c
d
e
f
g
TOTAL EARNINGS
INCLUDES MODIFICATION THRU:
TO DATE
TOTAL CONTRACT
$
$
12. PRESENTED FOR PAYMENT
14 A. PREVIOUS DEDUCTIONS OTHER THAN
RETAINED PERCENTAGE**
PAYEE
PER
B. PREVIOUS RETAINED PERCENTAGE
C. PREVIOUS PAYMENTS
DATE
TITLE
D. PREVIOUS EARNINGS (A+B+C)
E. EARNINGS THIS PERIOD (TOTAL
13. APPROVED FOR PAYMENT
EARNINGS TO DATE MINUS D)
I CERTIFY that I have checked the quantities covered by this bill or estimate; that
F. LESS RETAINED PERCENTAGE
the work was actually performed; that the quantities are correct and consistent
with all previous computations as actually checked; that the quantities and
G. LESS DEDUCTION OTHER THAN
amounts are wholly consistent with the requirements of the contract or other
H. TOTAL DEDUCTIONS FOR THIS PERIOD (F+G)
instrument involved.
SIGNATURE
TITLE
DATE
I. RETAINAGE REFUNDED
J. OTHER REFUNDS
K. TOTAL REFUNDS THIS PERIOD
L. AMOUNT DUE CONTRACTOR (E - H+K)
CONTRACTING OFFICER APPROVAL (Signature)
DATE
15. RECAPITULATION:
TOTAL RETAINED PCTG. (B+F - I)
TOTAL PAID (C+L)
**(USE REVERSE SIDE FOR DETAILED EXPLANATION AND-OR REMARKS) REMARKS)
FORM
PREVIOUS EDITION OF THIS FORM IS OBSOLETE.
ENG
93
1 MAR 78
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