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FIU PARTIAL PAYMENT

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FIU PARTIAL PAYMENT Powered By Docstoc
					                                                                                                                             instructions
Payment Requisition Form and Routing Slip
THIS FORM REPLACES THE BOARD OF REGENTS CERTIFICATE OF PARTIAL PAYMENT FORM DATED 2/13/96. CONTRACTORS / CONSTRUCTION MANAGERS
MAY OBTAIN AN ELECTRONIC VERSION OF THIS FORM FOR THEIR USE IN SUBMITTAL OF APPLICATIONS FOR PAYMENT. COPIES MAY BE REQUESTED
FROM THE FIU PROJECT MANAGER OR DOWNLOADED OFF THE FIU WEBSITE http://facilities.fiu.edu/fpc.htm.

AN EXECUTED AND NOTARIZED COPY OF THE APPLICATION SHALL BE SUBMITTED TO THE ARCHITECT-OF-RECORD. A COMPLETED ELECTRONIC COPY
SHALL BE SENT VIA EMAIL TO THE FIU PROJECT MANAGER. DO NOT RENAME THE FILE WHEN SUBMITTING TO FIU.
THE LAST TWO TABS PROVIDE A CLEAN VERSION OF THE FORMS FOR TYPE WRITTEN OR MANUAL SUBMISSIONS.
FILES ARE LOCKED AND PASSWORD ENABLED. NO ENTRIES CAN BE MADE OTHER THAN TO THOSE CELLS WHERE INFORMATION IS REQUIRED TO
COMPLETE THE PAYMENT APPLICATION.
NOTE: NO ENTRIES CAN BE MADE TO THE ROUTING SLIP AS IT COLLECTS ALL INFORMATION FROM THE CERTIFICATION FORM. YOU NEED ONLY PRINT IT
OUT FOR EACH PAYMENT APPLICATION. ALL COMPUTATION OF TOTALS ARE PROGRAMMED INTO THE FORM. SEE COMPLETED SAMPLE TAB SHEET.


                                                                                    Fields in gray tone with blue font color text are intended to be completed by
Change Order Deductions to Date:           $                    (152,635.65)        the GC/CM
            FIU Purchase Order (PO):                       PO 899211                Fields highlighted in yellow are for University use only.


                                       If prompted, please check off on the appropriate entry box.

                                                                                    If you see a small red triangle on right top corner of a cell, move mouse to cell
Original Contractor Sum:                   $                   5,299,000.00         to open the instruction text.
                                       January 1, 2004                              A field with a line entry for date or other to be completed by GC/CM
                                       Date




FIU/Facilities Planning and Construction                                                                                                             0404 Edition
                                                                                                       FIU Major Project Number (BR/BT):        BT 888
                                                                                                          FIU Minor Project Number (FM):        00 0000
Certificate for Payment Request                                                                                 FIU Purchase Order (PO):        PO 899211

Payment No:                             01                                                                                                      PARTIAL PAYMENT:
                                                                                                                                                FINAL PAYMENT
Contractor:                             HTGT CONTRACTORS
Construction Manager:                                                                                                 FIU Project Manager: John Q. Public
Address:                                6666 sw 66 st                                                                       e-mail address: sample@fiu.edu
City/State                              Miami, FL 99999-9999                                                                   Period from: December 1, 2003
Project Name:                           BUILDING ABC RENOVATIONS - MISCELLANEOUS                                                   Period to: December 31, 2003
                                        CHANGES TO FLOORS 2 AND 3 OF THE WEST WING
                                        STUDENT SERVICES AREA



O r iginal C ontr actor Sum:             $                                              15,285,537.00           Notice to P r oceed:     January 1, 2003
Change Order Additions to Date:          $                                                 305,808.00      2.0% Original Contract Time
Change Order Deductions to Date:         $                                                        -        0.0%         (calendar days): 450
Net Change Orders to Date:               $                                                 305,808.00      2.0%          Approved Time
                                                                                                                             Extensions: 10
A djusted C ontr act Sum:                $                                       15,591,345.00                Adjusted Contract Time: 460
Balance to Finish:                       $                                               5,283,439.33              Substantial Completion:      April 5, 2004
Work Performed to Date:                  $                                              10,307,905.67
                                                                                                                     Contract Time Lapsed
Materials Stored:                        $                                                         -                               to date: 79.1%
Total Certified to Date:                 $                                       10,307,905.67              ####                Retainage: 10.0%
Less Retainage:                          $                                               1,030,790.57
Released Retainage:                      $                                                 245,703.60
Balance:                                 $                                               9,522,818.70
Less Prev ious Pay ments:                $                                               8,540,530.56       ####
Due This Payment:                        $                                        982,288.14
                                        To the best of my knowledge and belief, I certify that all items and amounts shown on the face of this Certificate are true and
                                        correct, that all work has been performed and material supplied in full accordance with the terms and conditions of the Contract,
  CERTIFICATION OF                      and that all just and lawful bills against the undersigned and its subcontractors for labor and equipment employed in the
                                        performance of this Contract have been paid in full in accordance with their terms and conditions.
 THE CONTRACTOR:                        I hereby certify that all subcontractors providing services for the Work are licensed in accordance with Florida Statutes.



January 1, 2004                                                                         (Manual Signature)
Date                                                                                        Name / Ttile:          John Q. Public, Vice President
                                                                 Contractor / Construction Manager Name:           HTGT CONTRACTORS

                           State of:    Florida
                        County of:      Miami-Dade
 Suscribed and sworn before me this     30th
                             day of     January, 2004
                                                                                           (Manual Signature)
                                                                                                                   Notary Public
                                                                                                                   (Printed, typed or affixed stamp of commissioned
                                                                                                                   Notary Public including Name, State, Commission #
                                                                                                                   and Expiration Date)

                                        I certify that I have reveiwed and verified this payment requisition; that to the best of my knowledge and belief the above
 CERTIFICATION OF                       Certification is a true statement of the value of the work performed and the materials suitably stored on the site; that all work and
THE ARCHITECT OR                        materials included in this Certificate have been inspected by me or my authorized representatives; that all work has been
                                        performed and materials supplied in full accordance with the terms of this Contract, and I approve for payment the amount noted
       ENGINEER:                        above.

January 1, 2004                                                                            (Manual Signature)
Date                                                                                                               Architect/Engineer
                                                                                                                   DEF Architects

REVIEWED AND APPROVED FOR PAYMENT:
January 1, 2004                                                                            (Manual Signature)
Date                                                                                                               Director or Designee




                  FIU/Facilities Planning and Construction                                                                                                                      0404 Edition
FIU/Facilities Planning and Construction   0404 Edition
FIU/Facilities Planning and Construction   0404 Edition
                                                                                 FIU Major Project Number (BR/BT):   BT 000
                                                                                                      Payment No:    00
Payment Requisition Routing Slip                                                    FIU Minor Project Number (FM):   00 0000
Payment No:                                  00                                          FIU Purchase Order (PO):    PO 000000
Contractor or                                0
Construction Manager:                                                                               University PM: 0
Address:                                     0
City/State                                   0
Project Name:                                0




                                             EACH RECIPIENT IS REQUESTED TO ACT PROMPTLY IN HANDLING, TO RECORD DATES AS INDICATED
                                             BELOW AND TO MAINTAIN A RECORD OF ACTION.
                                             THIS FORM MUST ACCOMPANY AND PRECEDE EACH MONTHLY PAYMENT
                                             REQUEST
CONDITIONS PRECEDENT TO PAYMENT APPROVAL
TO THE BEST OF THE REVIEWERS' KNOWLEDGE AND BELIEF, THIS PAYMENT APPLICATION IS ACCURATE AND ITS CONTENTS ARE IN
COMPLIANCE WITH THE TERMS AND CONDITIONS OF THE CONTRACT INCLUDING, BUT NOT LIMITED TO, THE FOLLOWING SPECIFIC
ITEMS:

  YES           NO          NOT APPLICABLE DESCRIPTION OF CONDITIONS PRECEDENT
                                             1. CONSTRUCTION COST REIMBURSEMENT SUBMITTED IN COMPLIANCE WITH CHANCELLOR'S
                                             MEMORANDA CM-N-08.00-09/07. THE SUM OF ALL COSTS SUBMITTED ARE DIRECTLY
                                             SUPPORTED BY INVOICES FROM SUBCONTRACTORS AND/OR SUPPLIERS.
                                             2. BILLINGS DO NOT INCLUDE DISALLOWED COSTS SUCH AS UNAPPROVED BONUSES,
                                             OVERTIME, OR DUPLICATE PAYROLL CHARGES.
                                             3. PAYROLL TIME SHEETS SUBMITTED INCLUDE EMPLOYEE SIGNATURES FOR CURRENT
                                             BILLING PERIOD.
                                             4. ALL SELF-PERFORMED WORK INCLUDED IN THIS APPLICATION HAS PRIOR WRITTEN
                                             OWNER'S APPROVAL
                                             5. IF APPLICABLE, COPIES OF BUILDERS' RISK, LIABILITY INSURANCE COSTS ARE DIRECTLY
                                             SUPPORTED BY INVOICES FROM INSURANCE CARRIERS.
                                             6. IF APPLICATION FOR PAYMENT IS A FINAL APPLICATION, IT IS
                                             ACCOMPANIED BY A COPY OF AN EXECUTED FIU BUILDING CODE
                                             ADMINISTRATION CERTIFICATE OF OCCUPANCY OR COMPLETION
                                 REMARKS:




                                             Date Received:     Initial:     Date Processed:      Initial:
CONTRACTOR OR CONSTRUCTION
MANAGER (Submit Request)                                                                                                               DUR
ARCHITECT/ENGINEER
(Check and Approve)                                                                                                                      0
UNIVERSITY PROJECT MANAGER
(Approve)                                                                                                                                0
UNIVERSITY FM ACCOUNTING
(Check)                                                                                                                                  0
UNIVERSITY FM INTERNAL AUDITOR
(Check)                                                                                                                                  0
UNIVERSITY FC DIRECTOR
(Approve)                                                                                                                                0
Other______________________________
(Approve)                                                                                                                                0
ORIGINAL TO PROJECT FILE
UNIVERSITY ACCOUNTS PAYABLE
(Voucher)

WARRANT TO CONTRACTOR
                                                                                                                                         0
FIU PAY APP rev 2008 0528




  FIU/Facilities Planning and Construction                                                                              0404 Edition
                                                                                                                 FIU Capital Project Number (BR/BT):
                                                                                                                     FIU Minor Project Number (FM):

Certificate for Payment Request                                                                                            FIU Purchase Order (PO):


Payment No:                                                                                                                                                PARTIAL PAYMENT
                                                                                                                                                           FINAL PAYMENT
Contractor:
Construction Manager:                                                                                                     University Project Manager:
Address:                                                                                                                               e-mail address:
City/State                                                                                                                                Period from:
Project Name:                                                                                                                                 Period to:




O r iginal C ontr actor Sum:                                                                                               Notice to P r oceed:
Change Order Additions to Date:                                                                                        ####   Original Contract Time
Change Order Deductions to Date:                                                                                       ####          (calendar days):
Net Change Orders to Date:             $                                                                     -         ####           Approved Time
                                                                                                                                          Extensions:
A djusted C ontr act Sum:               $                                                                -               Adjusted Contract Time:           0
Balance to Finish:                     $                                                                     -                Substantial Completion:
Work Performed to Date:
                                                                                                                               Contract Time Lapsed
Materials Stored:                                                                                                                            to date:
Total Certified to Date:                $                                                                -             ####               Retainage: 10.0%
Less Retainage:                        $                                                                     -                       CHECK HERE IF CONTRACT TIME IS NOT APPLICABLE

Released Retainage:                                                                                                            (FOR MINOR PROJECTS OF A LIMIT ED SCOPE ONLY) .

Balance:                               $                                                                     -
Less Prev ious Pay ments:                                                                                              ####
Due This Payment:                       $                                                            -
                                       To the best of my knowledge and belief, I certify that all items and amounts shown on the face of this Certificate are true and correct,
                                       that all work has been performed and material supplied in full accordance with the terms and conditions of the Contract, and that all
  CERTIFICATION OF                     bills against the undersigned and its subcontractors for labor and equipment employed in the performance of this Contract have been
                                       paid in full in accordance with their terms and conditions and that no suits are pending by reason of work on the project under the
 THE CONTRACTOR:                       Contract; that all workmen's compensation claims have been settled and that no public liability claims are pending;
                                       I hereby certify that all subcontractors providing services for the Work are licensed in accordance with Florida Statutes.



                                                                                            (Manual Signature)
Date                                                                                            Name / Title:
                                                                     Contractor / Construction Manager Name:                                                                      0

                           State of:
                        County of:
Subscribed and sworn before me this
                             day of
                                                                                                (Manual Signature)
                                                                                                                              Notary Public
                                                                                                                              (Printed, typed or affixed stamp of commissioned
                                                                                                                              Notary Public including Name, State, Commission #
                                                                                                                              and Expiration Date)


 CERTIFICATION OF                      I certify that I have reviewed and verified this payment requisition; that to the best of my knowledge and belief the above Certification is
                                       a true statement of the value of the work performed and the materials suitably stored on the site; that all work and materials included in
THE ARCHITECT OR                       this Certificate have been inspected by me or my authorized representatives; that all work has been performed and materials supplied
                                       in full accordance with the terms of this Contract, and I approve for payment the amount noted above.
       ENGINEER:
                                                                                                (Manual Signature)
Date                                                                                                                          Architect/Engineer


REVIEWED AND APPROVED FOR PAYMENT:
                                                                                                (Manual Signature)
Date                                                                                                                          Director or Designee




                FIU/Facilities Planning and Construction                                                                                                                              0404 Edition
FIU/Facilities Planning and Construction   0404 Edition
FIU/Facilities Planning and Construction   0404 Edition
                                                                                 FIU Major Project Number (BR/BT):

                                                                                                      Payment No:

Payment Requisition Routing Slip                                                    FIU Minor Project Number (FM):

Payment No:                                                                              FIU Purchase Order (PO):


Contractor or
Construction Manager:                                                                               University PM:
Address:
City/State
Project Name:




                                             EACH RECIPIENT IS REQUESTED TO ACT PROMPTLY IN HANDLING, TO RECORD DATES AS INDICATED
                                             BELOW AND TO MAINTAIN A RECORD OF ACTION.



CONDITIONS PRECEDENT TO PAYMENT APPROVAL
TO THE BEST OF THE REVIEWERS' KNOWLEDGE AND BELIEF, THIS PAYMENT APPLICATION IS ACCURATE AND ITS CONTENTS ARE IN
COMPLIANCE WITH THE TERMS AND CONDITIONS OF THE CONTRACT INCLUDING, BUT NOT LIMITED TO, THE FOLLOWING SPECIFIC
ITEMS:

 YES           NO           NOT APPLICABLE DESCRIPTION OF CONDITIONS PRECEDENT
                                             1. CONSTRUCTION COST REIMBURSEMENT SUBMITTED IN COMPLIANCE WITH CHANCELLOR'S
                                             MEMORANDA 0800-09/07. THE SUM OF ALL COSTS SUBMITTED ARE DIRECTLY SUPPORTED BY
                                             INVOICES FROM SUBCONTRACTORS AND/OR SUPPLIERS.
                                             2. BILLINGS DO NOT INCLUDE DISALLOWED COSTS SUCH AS UNAPPROVED BONUSES OR
                                             DUPLICATE PAYROLL CHARGES.
                                             3. PAYROLL TIME SHEETS SUBMITTED INCLUDE EMPLOYEE SIGNATURES FOR CURRENT
                                             BILLING PERIOD.
                                             4. ALL SELF-PERFORMED WORK INCLUDED IN THIS APPLICATION HAS PRIOR WRITTEN
                                             OWNER'S APPROVAL
                                             5. IF APPLICABLE, COPIES OF BUILDERS' RISK, LIABILITY INSURANCE COSTS ARE DIRECTLY
                                             SUPPORTED BY INVOICES FROM INSURANCE CARRIERS.
                                             6. IF APPLICATION FOR PAYMENT IS A FINAL APPLICATION, IT IS ACCOMPANIED BY A COPY OF
                                             AN EXECUTED FIU BUILDING CODE ADMINISTRATION CERTIFICATE OF OCCUPANCY OR
                                             COMPLETION
                                 REMARKS:




CONTRACTOR OR CONSTRUCTION
MANAGER (Submit Request)
ARCHITECT/ENGINEER
(Check and Approve)
UNIVERSITY PROJECT MANAGER
(Approve)
UNIVERSITY FC ACCOUNTING
(Check)
UNIVERSITY FM INTERNAL AUDITOR
(Check)
UNIVERSITY FC DIRECTOR
(Approve)
Other______________________________
(Approve)                                                                                                                                     0
ORIGINAL TO PROJECT FILE
UNIVERSITY ACCOUNTS PAYABLE
(Voucher)

WARRANT TO CONTRACTOR
FIU PAY APP rev 2008 0528




  FIU/Facilities Planning and Construction                                                                                     0404 Edition
                                                                                                                       FIU Major Project Number (BR/BT):
                                                                                                                           FIU Minor Project Number (FM):

Certificate for Payment Request                                                                                                   FIU Purchase Order (PO):


Payment No:                                                                                                                                                      PARTIAL PAYMENT:
                                                                                                                                                                 FINAL PAYMENT
Contractor:
Construction Manager:                                                                                                            University Project Manager:
Address:                                                                                                                                      e-mail address:
City/State                                                                                                                                       Period from:
Project Name:                                                                                                                                       Period to:




O r iginal C ontr actor Sum:                                                                                                     Notice to P r oceed:
Change Order Additions to Date:
                                                                                                                                     Original Contract Time
Change Order Deductions to Date:                                                                                                            (calendar days):
Net Change Orders to Date:
                                                                                                                                              Approved Time
                                                                                                                                                 Extensions:
A djusted C ontr act Sum:                                                                                                       Adjusted Contract Time:
Balance to Finish:                                                                                                                  Substantial Completion:

Work Performed to Date:
                                                                                                                                      Contract Time Lapsed
Materials Stored:                                                                                                                                   to date:
T otal C er tified to Date:                                                                                                                      Retainage:
                                                                                                                                       CHECK HERE IF CONTRACT TIME IS NOT APPLICABLE
Less Retainage:
Released Retainage:                                                                                                                    FOR MINOR PROJECT S OF A LIMIT ED SCOPE ONLY

Balance:
Less Prev ious Pay ments:
Due This Payment:
                                         To the best of my knowledge and belief, I certify that all items and amounts shown on the face of this Certificate are true and correct, that all work
                                         has been performed and material supplied in full accordance with the terms and conditions of the Contract, and that all bills against the
  CERTIFICATION OF                       undersigned and its subcontractors for labor and equipment employed in the performance of this Contract have been paid in full in accordance
                                         with their terms and conditions and that no suits are pending by reason of work on the project under the Contract; that all workmen's compensation
 THE CONTRACTOR:                         claims have been settled and that no public liability claims are pending;
                                         I hereby certify that all subcontractors providing services for the Work are licensed in accordance with Florida Statutes.



                                                                                                             (Manual Signature)
Date                                                                                                          Name / Ttile:
                                                                                   Contractor / Construction Manager Name:

                           State of:
                        County of:
 Suscribed and sworn before me this
                             day of
                                                                                                             (Manual Signature)
                                                                                                                                    Notary Public
                                                                                                                                    (Printed, typed or affixed stamp of commissioned
                                                                                                                                    Notary Public including Name, State, Commission #
                                                                                                                                    and Expiration Date)


 CERTIFICATION OF                        I certify that I have reviewed and verified this payment requisition; that to the best of my knowledge and belief the above Certification is a true
                                         statement of the value of the work performed and the materials suitably stored on the site; that all work and materials included in this Certificate
THE ARCHITECT OR                         have been inspected by me or my authorized representatives; that all work has been performed and materials supplied in full accordance with the
                                         terms of this Contract, and I approve for payment the amount noted above.
       ENGINEER:
                                                                                                             (Manual Signature)
Date                                                                                                                                 Architect/Engineer
                                                                                                    Architect/Engineer's Name:

REVIEWED AND APPROVED FOR PAYMENT:
                                                                                                             (Manual Signature)
Date                                                                                                                                 Director or Designee
FIU PAY APP rev 2008 0528                                                                                                           FIU Facilities Construction




                   FIU/Facilities Planning and Construction                                                                                                                                       0404 Edition
FIU/Facilities Planning and Construction   0404 Edition
FIU/Facilities Planning and Construction   0404 Edition

				
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