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CITY OF NEW YORK

DEPARTMENT OF DESIGN AND CONSTRUCTION

DIVISION OF STRUCTURES

SUBCONTRACT SUMMARY FORM

(This form is to be completed by the CM for all construction subcontracts on CM Build & CM Design Build contracts and included in all requests for payment. For multi-site contracts, provide sub-totals for each site. For Requirement Contracts, complete one form for each Task Order.)

CONTRACT REG. NO. _________________________ TASK ORDER NO. ____________ FMS ID # (S) __________________________________________________________ PAYMENT NO. ________

WORK PERIOD: FROM _______TO _______ ORIGINAL CONSTRUCTION SERVICE ALLOWANCE: $ ________________ CURRENT CONSTRUCTION SERVICE ALLOWANCE: $ ________________

A |

B |

C |

D |

E |

F |

G |

H |

I |

J |

K |

L |

M | |

SITE ID # |

TRADE |

SUB

CONTRACTOR |

ORIGINAL SUBCONTRACT AMT |

APPROVED SUBCONTRACT CHANGE ORDERS |

TOTAL SUBCONTRACT AMT (D + E) |

WORK COMPLETED

|

TOTAL COMPLETED TO DATE (G + H) |

%

(I\F) |

TOTAL RETAINAGE

TO DATE |

TOTAL TO DATE

(I - J) |

PAID TO DATE

|

CURRENT AMOUNT DUE

(K - L) | | | | | | | |

FROM PREVIOUS APPLICATIONS

(G + H) |

THIS PERIOD | | | | | | | |

|

|

|

|

|

|

|

|

|

|

|

|

|

| |

|

|

TOTAL THIS SHEET |

$ |

$ |

$ |

$ |

$ |

$ |

X |

$ |

$ |

$ |

$ | |

|

|

GRAND TOTAL |

$ |

$ |

$ |

$ |

$ |

$ |

X |

$ |

$ |

$ |

$ | |

I certify that the information above is complete and accurate. I understand that the submission of fraudulent information in a requisition for payment may, at a minimum, result in the termination of the contract for cause and may render the firm not responsible for the award of future contracts from the City of New York.

BY:

__________________________________________________ _______________________________________________ __________________________________ ___________________________________________________ ___________________

(Print CM Company name) (Print CM Representatives name) (Title) (Signature) (Date)

Sheet ____of ______ rev. 01/15/98

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