PHL Invoice Summary Form by changcheng2

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									                                                               PHILADELPHIA INTERNATIONAL AIRPORT
                                                                     INVOICE SUMMARY FORM
Name of Prime Contractor                                                                                              Contract #
Type of Contract Services                                                                                             Encumbrance #                                     (If applicable)
Original Contract Amount                                                                                              Payments Received
Current Contract Amount                                                                                               Retainage Withheld                                (Public Works only)
Invoice Period                                          From                         Through                          Date Submitted


                                                                                                  Place 'X' in each                                                                            %
                                        BUSINESS ADDRESS                                %             Category                     MONTHLY CONTRACT INFORMATION                                C
                                                                                    Committed       that qualifies                                                                             O
                                                                                       per
          NAME OF SUBCONTRACTOR                                                                                                                                                                M
                                                                  DESCRIPTION        Contract
   #       (List ALL subcontractors:                                                              *               D          TOTAL                                                             P
                                                                   OF WORK                            M     W
            both DBE and non-DBE)                                                                 D               S         CURRENT                TOTAL PAYMENTS           AMOUNT THIS        L
                                         (CITY, STATE, ZIP)                         (for DBE or       B     B
                                                                                                  B               B       SUBCONTRACT                 TO DATE                 INVOICE          E
                                                                                       M/W/           E     E
                                                                                                  E               E         AMOUNT                                                             T
                                                                                    DSBE only)
                                                                                                                                                                                               E

   1                                                                                                                  $                    -   $                    -   $                 -   #####

   2                                                                                                                  $                    -   $                    -   $                 -   #####

   3                                                                                                                  $                    -   $                    -   $                 -   #####

   4                                                                                                                  $                    -   $                    -   $                 -   #####

   5                                                                                                                  $                    -   $                    -   $                 -   #####

   6                                                                                                                  $                    -   $                    -   $                 -   #####

   7                                                                                                                  $                    -   $                    -   $                 -   #####

   8                                                                                                                  $                    -   $                    -   $                 -   #####

   9                                                                                                                  $                    -   $                    -   $                 -   #####

   10                                                                                                                 $                    -   $                    -   $                 -   #####

                                                         SUBCONTRACTOR TOTALS            0.00%                        $                    -   $                    -   $                 -

                                                 PRIME CONTRACTOR TOTAL                                               $                    -   $                    -   $                 -

                                                               TOTAL THIS INVOICE                                                                                       $                 -


* PUT AN "X" IN THIS COLUMN ONLY IF SUBCONTRACTOR IS A FEDERALLY CERTIFIED DBE.


I certify that the information furnished above is correct to the best of my knowledge and represents the current status of the firm's (Prime Contractor) subcontract(s)
with the listed firms (Subcontractors) for the designated period covered by this report.

Signed:                                                                                           Title:                                                      Date:

                                                       This form must be attached to all invoices submitted by the Prime Contractor.

                                                                                                                                                                                              07/2012

								
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