Payment Requisition, Part A (for contract work)
Sheet ______ of _____ Sheets
DEPARTMENT OF DESIGN AND CONSTRUCTION
DIVISION OF STRUCTURES
PAYMENT REQUISITION: Part A
(For Contract Work and Contract Change Work [or Task Order Work] - Consultant including CM Manager)
FOR PAYMENT NO. ______________ FROM ________________ TO _________________ INCLUSIVELY FMS (CAPIS) ID ____________________ TASK ORDER NO. _____________
(Please use sequential numbers for all payments on this Contract; for Requirements Contracts, number payments sequential to each Task Order.)
CONTRACT REG. NO. _____________________ CONTRACT TITLE ________________________________________________________________ CONTRACT REG. DATE _______________
PROJECT ___________________________________________ ADDRESS _____________________________________________________________ BORO. ______________________________
(For Requirements Contracts, use separate sheet for each Task Order associated with this Contract. Task Order requisitions must list all registered Supplemental Task Orders.)
CONSULTANT’S NAME ______________________________________ ADDRESS ________________________________________ TELE. ___________________ FAX _____________________
| | | | |E | | | |
|A |B |C |D | |F |G |H |
| |LUMP SUM OR NOT TO EXCEED AMOUNT |
% |
VALUE
(C x D) |
FROM PREVIOUS
APPLICATIONS
(H) |
THIS PERIOD | | | | | |
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SUBTOTALS (THIS SHEET) |
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TOTALS (LAST SHEET) |
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| | * IDENTIFY THE VARIOUS PORTIONS OF THE PROJECT AND THE CONSULTANT'S SERVICES CONSISTENT WITH THE VALUES AND SERVICES IN THE CONTRACT OR TASK ORDER. SEE INSTRUCTIONS.
** FOR CM MANAGERS (IF APPLICABLE)
*** SIGNATURE SIGNIFIES RECEIPT (NOT APPROVAL) OF PAYMENT
RECEIVED FROM CONSULTANT __________________________________________________________________ DATE: _________________________
(PM SIGNATURE)*** (Receipt Date)
1_2req.doc 9/29/2002; rev. 06/11/03
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