Contractor Payment Request Short Form

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					Instructions for Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

The Contractor Payment Request workbook was created in Microsoft Excel XP, Version 2003 SP2. There are 10
worksheet tabs that comprise the entire document The last tab is for office use only and is not completed by the
contractor. In most of the tabs there are multiple pages. Please review the entire document prior to commencing.
The Contractor Payment Request is to provide an accurate and detailed breakdown for the Work, in accordance with
the requirements of Article 9 of the General Conditions and following the preferred titles and sequences in the
Construction Specifications Institute (CSI) used in the Specifications. The Architect/Engineer and the Construction
Manager (if applicable) will review the Contractor Payment Request for accuracy and completeness; no payment will be
made without an approved Contractor Payment Request

The detail required on the schedule of values of the Contractor Payment Request is to allow for easy confirmation of the
status of each item of Work. For example, a multi-story building should include a “per floor” item for finish Work by the
general Contractor such as metal studs, drywall and paint; or a large single story building may be broken down “by wing”
and the same metal studs, drywall and paint. Mechanical and electrical Contractors will include separate line items for all
major pieces of equipment and group small equipment items by type. These trades are requested to follow the “per
floor” or “per wing” approach for rough in, wiring, and device hookup, or for piping and hookup. The line items for labor
and material shall accurately reflect the cost for each item; separate items are not to be shown for overhead or profit, but
should be included in the totals for labor and materials.

Legend
Cell Colors as Used on Forms
Yellow             Normal entry information
Turquoise          Information entered under special circumstances
Red                Enter maximum retainage only after first 50%+ pay request
Lavender           Information to copy from
Light Turquoise    Information to copy to
Pale Blue          Check appropriate box
Tan                Optional Area For Calculation


General Instructions for Contractor Payment Request
In accordance with Instructions to Bidders 6.4.1.5 of the Standard Conditions of Contract for Construction, all
Contractors must provide evidence that an authorization agreement for automatic deposit of state warrants has
been submitted to the Auditor of the State of Ohio. Use of electronic funds transfer (EFT) will normally result in
payment 7 to 10 days earlier than by State warrant.

Payment to the Contractor will be processed according to Article 9 of the General Conditions. The procedure for
reviewing and approving payment requests shall be established at the pre-construction meeting. On larger Projects, it is
advisable to distribute a pencil copy of the payment request for preliminary review by the Architect/Engineer and the
Construction Manager (if applicable) one week before formal submittal.

The Contractor will submit the required number of copies of the executed payment request. Original signatures are
required on all copies and are requested in blue ink. The payment request is processed by the Office of the State
Architect (SAO) and returned to the Owner for vouchering, however, some Owners prefer to review, approve and
voucher the payment request before submitting to SAO.




SAO-F140-02v1210                                                                               Instructions, Page 1 of 3
Instructions for Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186
The Contractor shall submit a certified payroll report with each payment request which includes labor, see Section
9.2.1.3 of the General Conditions. One (1) certified payroll report is required for each week of Work reflected on the
payment request. Any payment request, which does not include labor, requires a certified payroll report indicating the
period covered by the payment request specifically noting that “no labor was performed during this period.” SAO
requests one copy of the certified payroll reports (for the Contractor and all Subcontractors who performed labor for
requested period) be attached to the back of the second copy of the payment request to reduce the possibility that
someone requiring a copy of the payment request will also take the certified payroll.

The Contractor shall request payment for Change Orders which have been approved and for which Work was
performed during the time covered by the payment request.

If a Contractor is requesting payment for materials delivered on the Project site or other approved storage site, the
Contractor shall complete the Materials Stored section of this application. The Contractor shall pay any travel expenses
incurred by the Architect/Engineer or the Construction Manager (if applicable) to visit a storage site other than the
Project location.

Retainage is to be held on payment requests in the amount of eight percent (8%) of labor until a construction Contract
has reached fifty-percent (50%) completion. The calculation for determining whether the Contract has reached fifty-
percent (50%) completion is as follows: total labor and material “billed” to date to include approved stored materials
divided by total Contract amount plus total Change Orders approved to date. The Contractor will be asked by SAO to
sign an escrow agreement soon after Contract award. When a payment request is received that exceeds 50 percent as
calculated above, SAO will transfer the retainage into escrow where it will earn interest. If a Contractor fails to return the
escrow agreement, no escrow can be established.

In order to request final payment, the payment request must include the following: required payroll reports, a
Certification of Contract Completion evidencing that all Project record document submittals are satisfactory and an
Affidavit of Contractor to certify compliance with prevailing wage and payment to Subcontractors and Material Suppliers.


Escrow funds remain on account with the escrow agent until the final, 100 percent payment is requested, a Contract
Completion Certificate is issued and a signed Affidavit of Contractor has been received. At that time, escrow and earned
interest are released and forwarded to the Contractor. An early release of escrow may be allowed if Change Orders are
issued late in the Contract and the Contractor has completed 100 percent of the base Contract Work.

Step By Step Instructions
Initial Schedule of Values

  At the beginning of the Contract each Contractor is required to complete the basic information at the top of the Section
  A – Summary page (area in yellow except for request number and period) as well as columns a through d of Section B
  – Schedule of Values Summary (items 1 through 8 plus area in yellow) for as many line items as are required. Prior to
  entering the line items on Schedule B, the contractor should fill out Tab H - EDGE to include all EDGE subcontractors
  and suppliers expected to be used. The EDGE subcontractors must also be entered on Tab G - Subcontractors. Use
  of EDGE vendors must be identified on the Schedule of Values by entering the corresponding alpha character from
  column a of tab H - EDGE into column b of the Schedule of Values along with the other required data. The Schedule
  of Values must then be signed by the Contractor and submitted to the Architect/Engineer and the Construction
  Manager (if applicable) for approval. The Schedule of Values will then be forwarded to the Project Manager for final
  approval. The Contractor will receive a signed copy of the approved Schedule of Values. No payment requests will be
  processed before the Schedule of Values has been approved.



Note: If you are trying to enter data into a cell and get a pop-up warning that you cannot enter into a protected
cell you are trying to enter data where you should not be. Data is NEVER entered into a cell that is white or
lavender.



SAO-F140-02v1210                                                                                 Instructions, Page 2 of 3
Instructions for Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Payment Request
  1. Contractor Payment Requests are normally submitted on a monthly basis
  2. Enter Request No. and dates from and to on Section A – Summary

  3. Go to Section C – Schedule of Values Details. Enter amounts from previous applications in columns e and f (light
  turquoise). Enter amounts for current period in columns h and i. If you prefer you can move the cursor to the right, off
  the form and enter the percentage complete for any or all of the line items. Note: You should be able to copy the
  information you need to enter in columns c and d from Section B – Schedule of Values Summary columns k and l
  (lavender color) of the previous Contractor Payment Request. When you paste the information you will need to use
  "paste special and click on "values and number formats"

  4. Go to Section D - Change Order Summary. Enter all Change Orders that have been approved since the last
  payment request that was submitted in columns a through f (yellow area). You must separately identify EDGE vendors
  used.

  5. Go to Section E - Change Order Details. Enter amounts from previous applications in columns c and d (light
  turquoise). Enter amounts for current period in columns f and g. If you prefer you can move the cursor to the right, off
  the form and enter the percentage complete for any or all of the line items. Note: You should be able to copy the
  information you need to enter in columns c and d from Section D – Change Order Summary columns I and j (lavender
  color) of the previous Contractor Payment Request. When you paste the information you will need to use "paste
  special and click on "values and number formats"

  6. Go to Section F - Stored Materials. Enter information as required. Be sure to check each item as to whether stored
  on or off site.

  7. Go to Section G - Subcontractors. List ALL Subcontractors. Check whether or not each Subcontractor was used
  during the period covered by this request. Check whether or not payrolls are attached. Check whether or not
  apprenticeship agreement has been submitted. Check whether or not payrolls have been submitted for each
  Subcontractor. Note: You are responsible for obtaining and providing payrolls for all of the Subcontractors you use.
  Failure to provide payrolls for all Subcontractors used during the period of this request is a violation of your Contract.


  8. Go to Section A - Summary. Amounts completed to date have been calculated and carried forward to the summary
  page based upon the data you have entered. Retainage to date has also been calculated and entered. Also entered is
  the percentage that this Contract is now complete based upon the information entered. If the percent complete shows
  50% or more complete and this is the first pay request for which this has been the case the amount of retainage
  shown will be the final total for retainage for this contract and you should override the calculation for retainage on all
  future pay requests for this contract and enter this amount on all future pay requests. Enter the amounts which should
  be withheld for liens, Liquidated Damages or other withholdings about which you have been informed. Enter the
  amount of previous payments from previous pay request. At this point the form has calculated the amount due on this
  payment request.

  9. Print the Section A - Summary page. Then go to each tab (Worksheet) and print the number of pages on which you
  have entered data on this contract. Each Worksheet will display the number of pages on that Worksheet in the bottom
  right hand corner of every page. If it reads Page 1 of 5 in the bottom right you would want to print 5 pages of that
  Worksheet. The entire Workbook contains over 110 pages so you would not want to print all of the pages in the
  Workbook as many of them are unnecessary for most contracts.

  10. You should now have one copy of the entire Contractor Payment Request. Make as many copies of the payment
  request as the Architect/Engineer has told you that you will need to submit for this contract. Sign each copy. Attach
  the required payrolls to the second copy as instructed above. Submit all copies to the Architect/Engineer for approval
  and further processing.

  Please refer any questions or concerns about the forms to your project coordinator.

SAO-F140-02v1210                                                                                 Instructions, Page 3 of 3
Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Contractor Name and Address                            Project Information                              A/E Name and Address              A - Summary
                                                       UC Project No.
                                                       Purchase Order #                                                                   Request No.
                                                       Project Name & Location                                                            Sheet     1    of        1
Contr. Phone                                                                                            CM Name and Address
Contr. Fax                                                                                                                                For the period
Contr. Tax ID                                                                                                                             from
Contr. E-mail                                          Type of Contract                                                                   to


Contractor Certification                                             Partial Payment Details                    Labor $         Materials $              Total $
Contractor certifies the Original Application values in this         Completed to date
Payment Request have not changed from the values first                       Original Contract Amount
approved, all information in this Payment Request is true and
                                                                             Change Order Amount
accurate, all payments received to date have been used by the
Contractor to discharge, in full, the obligations incurred and
provided during the periods for which payment was made, and                  Stored Materials                             N/A
the Contractor has, to the best of its knowledge, completed the
Work to date in accordance within the terms and conditions of                Subtotal - Earned (A)
the contract, including payment of the applicable Prevailing                 Percent Complete
Wage rates.

                                                                     Withheld Amounts
Authorized signature                                  Date                  Lien(s)
                                                                            Retainage Amount
                                                                            Liquidated Damages
Work Progress Certification                                                 Other
Each firm signing below certifies that, based upon its on-
site observations, the payment requested to date is a fair
and reasonable request for the Work provided to date.                        Subtotal - Withheld (B)


                                                                     Previous Payments (C)
Architect/Engineer (A/E)                              Date

                                                                     Total Requested this
Construction Manager                                  Date           Application (A - B - C)

University Approval


Authorized signature                                  Date
SAO-F140-02v1210                                                                                                                       Section A - Summary, Page 1 of 1
Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Contractor Name                                                                              UC Project No.                                        B - Schedule of Values
Project Name                                                                                                                                           Summary
                                                                                             Purchase Order #                                      Request No.
Project Location                                                                                                                                   Sheet            2      of         1

                                                                           Original Application                                          Current Period
 a. b.            c.                          d.                   e.                f.              g.              h.          i.          j.             k.                   l.
       EDGE




                                                                Original         Original         Original      Completed to   % this      % to          Labor to           Material to
Item           Section                  Description             Labor $         Material $        Total $         Date $       Period      Date           Date $             Date $
 1             00 61 00     Bond
 2             00 62 16     Insurance
 3             00 72 00     General Conditions
 4             01 31 13     Project Coordination
 5             01 7 113     Mobilization
 6             01 77 00     Close-out Items
 7            01 21 00.01   Allowance: Sched. Consultant
 8            01 21 00.02   Allowance: Project Identification
 9
 10
 11
 12
 13
 14
 15
 16
 17
 18
 19
 20
 21
 22
 23
Total this Sheet


                                                                                                                                        Section B - Schedule of Values Summary, Page 1 of 0




      SAO-F140-02v1210
Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Contractor Name                                                            UC Project No.                                        B - Schedule of Values
Project Name                                                                                                                         Summary
                                                                           Purchase Order #                                      Request No.
Project Location                                                                                                                 Sheet            3      of         1

                                                         Original Application                                          Current Period
 a. b.          c.             d.                e.                f.              g.              h.          i.          j.             k.                   l.
       EDGE




                                              Original         Original         Original      Completed to   % this      % to          Labor to           Material to
Item          Section      Description        Labor $         Material $        Total $         Date $       Period      Date           Date $             Date $
 24
 25
 26
 27
 28
 29
 30
 31
 32
 33
 34
 35
 36
 37
 38
 39
 40
 41
 42
 43
 44
 45
 46
Total this Sheet


                                                                                                                      Section B - Schedule of Values Summary, Page 2 of 0




      SAO-F140-02v1210
Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Contractor Name                                                            UC Project No.                                        B - Schedule of Values
Project Name                                                                                                                         Summary
                                                                           Purchase Order #                                      Request No.
Project Location                                                                                                                 Sheet            4      of         1

                                                         Original Application                                          Current Period
 a. b.          c.             d.                e.                f.              g.              h.          i.          j.             k.                   l.
       EDGE




                                              Original         Original         Original      Completed to   % this      % to          Labor to           Material to
Item          Section      Description        Labor $         Material $        Total $         Date $       Period      Date           Date $             Date $
 47
 48
 49
 50
 51
 52
 53
 54
 55
 56
 57
 58
 59
 60
 61
 62
 63
 64
 65
 66
 67
 68
 69
Total this Sheet


                                                                                                                      Section B - Schedule of Values Summary, Page 3 of 0




      SAO-F140-02v1210
Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Contractor Name                                                            UC Project No.                                        B - Schedule of Values
Project Name                                                                                                                         Summary
                                                                           Purchase Order #                                      Request No.
Project Location                                                                                                                 Sheet            5      of         1

                                                         Original Application                                          Current Period
 a. b.          c.             d.                e.                f.              g.              h.          i.          j.             k.                   l.
       EDGE




                                              Original         Original         Original      Completed to   % this      % to          Labor to           Material to
Item          Section      Description        Labor $         Material $        Total $         Date $       Period      Date           Date $             Date $
 70
 71
 72
 73
 74
 75
 76
 77
 78
 79
 80
 81
 82
 83
 84
 85
 86
 87
 88
 89
 90
 91
 92
Total this Sheet


                                                                                                                      Section B - Schedule of Values Summary, Page 4 of 0




      SAO-F140-02v1210
Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Contractor Name                                                                                UC Project No.                                       C - Schedule of Values
Project Name                                                                                                                                            Details
                                                                                               Purchase Order #                                     Request No.
Project Location                                                                                                                                    Sheet           2       of          1


                                                                        Previous Applications to Date                                     Current Period
 a. b.            c.                          d.                   e.                f.               g.              h.             i.                      j.                   k.
       EDGE




                                                                Previous          Previous         Previous       Labor this   Material this             Labor to            Material to
Item           Section                  Description             Labor $           Material $        Total $        Period $     Period $                  Date $              Date $
 1             00 61 00     Bond
 2             00 62 16     Insurance
 3             00 72 00     General Conditions
 4             01 31 13     Project Coordination
 5             01 7 113     Mobilization
 6             01 77 00     Close-out Items
 7            01 21 00.01   Allowance: Sched. Consultant
 8            01 21 00.02   Allowance: Project Identification
 9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Total this Sheet


                                                                                                                                          Section C - Schedule of Values Details, Page 1 of 0



         SAO-F140-02v1210
Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Contractor Name                                                              UC Project No.                                       C - Schedule of Values
Project Name                                                                                                                          Details
                                                                             Purchase Order #                                     Request No.
Project Location                                                                                                                  Sheet           3       of          1


                                                      Previous Applications to Date                                     Current Period
 a. b.          c.              d.               e.                f.               g.              h.             i.                      j.                   k.
       EDGE




                                              Previous          Previous         Previous       Labor this   Material this             Labor to            Material to
Item          Section       Description       Labor $           Material $        Total $        Period $     Period $                  Date $              Date $
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
Total this Sheet


                                                                                                                        Section C - Schedule of Values Details, Page 2 of 0



         SAO-F140-02v1210
Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Contractor Name                                                              UC Project No.                                       C - Schedule of Values
Project Name                                                                                                                          Details
                                                                             Purchase Order #                                     Request No.
Project Location                                                                                                                  Sheet           4       of          1


                                                      Previous Applications to Date                                     Current Period
 a. b.          c.              d.               e.                f.               g.              h.             i.                      j.                   k.
       EDGE




                                              Previous          Previous         Previous       Labor this   Material this             Labor to            Material to
Item          Section       Description       Labor $           Material $        Total $        Period $     Period $                  Date $              Date $
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
Total this Sheet


                                                                                                                        Section C - Schedule of Values Details, Page 3 of 0



         SAO-F140-02v1210
Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Contractor Name                                                              UC Project No.                                       C - Schedule of Values
Project Name                                                                                                                          Details
                                                                             Purchase Order #                                     Request No.
Project Location                                                                                                                  Sheet           5       of          1


                                                      Previous Applications to Date                                     Current Period
 a. b.          c.              d.               e.                f.               g.              h.             i.                      j.                   k.
       EDGE




                                              Previous          Previous         Previous       Labor this   Material this             Labor to            Material to
Item          Section       Description       Labor $           Material $        Total $        Period $     Period $                  Date $              Date $
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
Total this Sheet


                                                                                                                        Section C - Schedule of Values Details, Page 4 of 0



         SAO-F140-02v1210
                                                                            Optional Calculation
                                                                          Labor Material % To
                                                                         Percent Percent Date




                   Section C - Schedule of Values Details, Page 1 of 0



SAO-F140-02v1210
                                                                            Optional Calculation
                                                                          Labor Material % To
                                                                         Percent Percent Date




                   Section C - Schedule of Values Details, Page 2 of 0



SAO-F140-02v1210
                                                                            Optional Calculation
                                                                          Labor Material % To
                                                                         Percent Percent Date




                   Section C - Schedule of Values Details, Page 3 of 0



SAO-F140-02v1210
                                                                            Optional Calculation
                                                                          Labor Material % To
                                                                         Percent Percent Date




                   Section C - Schedule of Values Details, Page 4 of 0



SAO-F140-02v1210
Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Contractor Name                                                                UC Project No.                                 D - Change Order
Project Name                                                                                                                      Summary
                                                                               Purchase Order #                               Request No.
Project Location                                                                                                              Sheet           2      of        1

                                                         Change Order Info                                            Current Period
  a.     b.        c.          d.              e.               f.                g.            h.    i.         j.                    k.                 l.
         EDGE




                                          Change Order     Change Order      Change Order   % this   % to   Completed to           Labor to          Material to
CO No.          Section   Date Approved     Labor $         Material $          Total $     Period   Date     Date $                Date $            Date $




Total this Sheet

                                                                                                                       Section D - Change Order Summary, Page 1 of 0

   SAO-F140-02v1210
Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Contractor Name                                                                UC Project No.                                 D - Change Order
Project Name                                                                                                                      Summary
                                                                               Purchase Order #                               Request No.
Project Location                                                                                                              Sheet           3      of        1

                                                         Change Order Info                                            Current Period
  a.     b.        c.          d.              e.               f.                g.            h.    i.         j.                    k.                 l.
         EDGE




                                          Change Order     Change Order      Change Order   % this   % to   Completed to           Labor to          Material to
CO No.          Section   Date Approved     Labor $         Material $          Total $     Period   Date     Date $                Date $            Date $




Total this Sheet

                                                                                                                       Section D - Change Order Summary, Page 2 of 0

   SAO-F140-02v1210
Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Contractor Name                                                                UC Project No.                              D - Change Order
Project Name                                                                                                                   Summary
                                                                               Purchase Order #                            Request No.
Project Location                                                                                                           Sheet           4      of        1

                                                         Change Order Info                                        Current Period
  a.     b.        c.          d.              e.               f.                g.          h.      i.        j.                 k.                 l.
         EDGE




                                          Change Order     Change Order      Change Order   % this   % to   Completed to        Labor to          Material to
CO No.          Section   Date Approved     Labor $         Material $          Total $     Period   Date     Date $             Date $            Date $




Total this Sheet

                                                                                                                    Section D - Change Order Summary, Page 3 of 0

   SAO-F140-02v1210
Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Contractor Name                                                             UC Project No.                                         E - Change Order
Project Name                                                                                                                           Details
                                                                            Purchase Order #                                       Request No.
Project Location                                                                                                                   Sheet         2         of         1

                                                   Previous Applications to Date                                           Current Period
  a. b.            c.        d.               e.                f.               g.                 h.                i.                    j.                  k.
      EDGE




 CO                         Date        Previous              Previous         Previous        CO Labor this   CO Material this       CO Labor to        CO Material to
 No.           Section    Approved     CO Labor $           CO Material $     CO Total $         Period $         Period $              Date $              Date $




Total this Sheet


                                                                                                                              Section E - Change Order Details, Page 1 of 0
   SAO-F140-02v1210
Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Contractor Name                                                             UC Project No.                                         E - Change Order
Project Name                                                                                                                           Details
                                                                            Purchase Order #                                       Request No.
Project Location                                                                                                                   Sheet         3         of         1

                                                   Previous Applications to Date                                           Current Period
  a. b.            c.        d.               e.                f.               g.                 h.                i.                    j.                  k.
      EDGE




 CO                         Date        Previous              Previous         Previous        CO Labor this   CO Material this       CO Labor to        CO Material to
 No.           Section    Approved     CO Labor $           CO Material $     CO Total $         Period $         Period $              Date $              Date $




Total this Sheet


                                                                                                                              Section E - Change Order Details, Page 2 of 0
   SAO-F140-02v1210
Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Contractor Name                                                             UC Project No.                                         E - Change Order
Project Name                                                                                                                           Details
                                                                            Purchase Order #                                       Request No.
Project Location                                                                                                                   Sheet         4         of         1

                                                   Previous Applications to Date                                           Current Period
  a. b.            c.        d.               e.                f.               g.                 h.                i.                    j.                  k.
      EDGE




 CO                         Date        Previous              Previous         Previous        CO Labor this   CO Material this       CO Labor to        CO Material to
 No.           Section    Approved     CO Labor $           CO Material $     CO Total $         Period $         Period $              Date $              Date $




Total this Sheet


                                                                                                                              Section E - Change Order Details, Page 3 of 0
   SAO-F140-02v1210
                                                                     Optional Calculation for
                                                                          current period
                                                                    Labor Material % To
                                                                   Percent Percent Date




                   Section E - Change Order Details, Page 1 of 0
SAO-F140-02v1210
                                                                      Optional Calculation
                                                                    Labor Material % To
                                                                   Percent Percent Date




                   Section E - Change Order Details, Page 2 of 0
SAO-F140-02v1210
                                                                      Optional Calculation
                                                                    Labor Material % To
                                                                   Percent Percent Date




                   Section E - Change Order Details, Page 3 of 0
SAO-F140-02v1210
Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Contractor Name                                              UC Project No.                                          F - Stored Materials
Project Name
                                                             Purchase Order #                                        Request No.
Project Location                                                                                                     Sheet       2         of          1

               Line   Invoice     Material                                         Previous     New Materials   Mat. Installed this      Current Material
 On    Off     Ref.     No.       Supplier              Description             Stored Amount   Stored (Add)    Period (Deduct)              Stored




                                              Total This Sheet




                                                                                                                    Section F - Stored Materials, Page 1 of 0
SAO-F140-02v1210
Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Contractor Name                                              UC Project No.                                          F - Stored Materials
Project Name
                                                             Purchase Order #                                        Request No.
Project Location                                                                                                     Sheet       3         of          1

               Line   Invoice     Material                                         Previous     New Materials   Mat. Installed this      Current Material
 On    Off     Ref.     No.       Supplier              Description             Stored Amount   Stored (Add)    Period (Deduct)              Stored




                                              Total This Sheet
                                              Grand Total (Final Sheet Only)

                                              Payments Allowed @ 92%
                                                                                                                    Section F - Stored Materials, Page 2 of 0
SAO-F140-02v1210
Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Contractor Name                                    UC Project No.                                               G -       Subcontractors
Project Name
                                                   Purchase Order #                                             Request No.
Project Location                                                                                                Sheet     2       of          1

                   List all Subcontractors    Utilized This Pay Period   Payrolls Attached   Apprent. Agree. Submited     Pay. Sched. Submitted
                                                     Yes     No            Yes      No             Yes     No                  Yes     No
   1
   2
   3
   4
   5
   6
   7
   8
   9
   10
   11
   12
   13
   14
   15
   16
   17
   18
   19
   20
   21
   22
   23
   24
   25

                                                                                                               Section G - Subcontractors, Page 1 of 0
SAO-F140-02v1210
Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Contractor Name                                    UC Project No.                                               G -       Subcontractors
Project Name
                                                   Purchase Order #                                             Request No.
Project Location                                                                                                Sheet     3       of          1

                   List all Subcontractors    Utilized This Pay Period   Payrolls Attached   Apprent. Agree. Submited     Pay. Sched. Submitted
                                                     Yes     No            Yes      No             Yes     No                  Yes     No
   26
   27
   28
   29
   30
   31
   32
   33
   34
   35
   36
   37
   38
   39
   40
   41
   42
   43
   44
   45
   46
   47
   48
   49
   50

                                                                                                               Section G - Subcontractors, Page 2 of 0
SAO-F140-02v1210
Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Contractor Name                                     UC Project No.                                                     H - EDGE
Project Name
                                                    Purchase Order #                                    Request No.
Project Location                                                                                        Sheet     2        of         1

 a                              b               c              d          e            f         g        h                     i
Reference




                                                                       Projected   Projected   Actual   Actual
                                                             Award       Start       End        Start    End               Status
                               Name           Tax ID          Date       Date        Date       Date     Date      Active Complete Void
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T

                                                                                                                 Section H - EDGE, Page 1 of 0




            SAO-F140-02v1210
Contractor Payment Request
Division of Administration and Finance
Planning + Design + Construction
PO Box 210186 ▪ Cincinnati, Ohio 45221-0186

Contractor Name                                     UC Project No.                                                     H - EDGE
Project Name
                                                    Purchase Order #                                    Request No.
Project Location                                                                                        Sheet     3        of         1

 a                              b               c              d          e            f         g        h                     i
Reference




                                                                       Projected   Projected   Actual   Actual
                                                             Award       Start       End        Start    End               Status
                               Name           Tax ID          Date       Date        Date       Date     Date      Active Complete Void
U
V
W
X
Y
Z




                                                                                                                 Section H - EDGE, Page 2 of 0




            SAO-F140-02v1210

				
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