Payment Requisition, Part A (for JOC Contracts) by vow15418

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									                                                                                                                                                               Sheet ______ of _____ Sheets
                                                                         DEPARTMENT OF DESIGN AND CONSTRUCTION
                                                                      DIVISIONS OF STRUCTURES AND TECHNICAL SUPPORT
                                                                        PAYMENT REQUISITION: Part A
                                                                                (For JOC Contract Work-Contractor)
ESTIMATE FOR PAYMENT NO. ______________ FOR CONTRACT WORK                          FROM _______________ TO _________________ INCLUSIVELY             WORK ORDER (W.O.) # _____________
(Please number Work Order payments sequential to each Work Order.)
CONTRACT REG. NO.________________ CONTRACT LIMIT _________________ CONTRACT TITLE ____________________________________________ W.O. REG. DATE_____________
WORK ORDER START DATE_____________ WORK ORDER COMPLETION DATE____________ ORIG. W.O. SUM _____________________ FMS ID(S) _____________________________
PROJECT ___________________________________________ ADDRESS _____________________________________________________________ BORO. ______________________________
(Use separate sheet for each Work Order associated with this Contract. Work Order requisitions must list all registered Supplemental Work Orders.)
CONTRACTOR=S NAME ______________________________________ ADDRESS ________________________________________ TELE. ___________________ FAX ____________________
REGISTERED SUPPLEMENTAL W. O. # S ________________________________________________________________________________________________________________

   A                         B                            C              D                E                    F           G                  H                        I                  J
   A                         B                            C              D                             F
                                                                                          WORK COMPLETED                    G
                                                                                                                        MATERIALS        TOTAL
                                                                                                                                                                   BALANCE
                                                                      * TOTAL                                           PRESENTLY     COMPLETED                                      RETAINAGE
 * ITEM               * DESCRIPTION                  * QUANTITY                     FROM PREVIOUS                        STORED      AND STORED TO                    TO
                                                                    SCHEDULED                                                                           %                           (IF VARIABLE
   NO.       * (include unit price if applicable)       /UNITS
                                                                      VALUE          APPLICATIONS      THIS PERIOD        (NOT IN        DATE         (H\ D)
                                                                                                                                                                    FINISH
                                                                                                                                                                                         RATE)
                                                                                        (E + F)                           E OR F)      (E + F + G)                  (D - H)




                SUBTOTALS (THIS SHEET)

                  TOTALS (LAST SHEET)
                                                              * AS SHOWN IN THE CONTRACTOR=S ORIGINAL PROPOSAL SUMMARY AND ALL SUPPLEMENTAL CONTRACTOR=S PROPOSAL SUMMARIES.

                                                         RECEIVED FROM CONTRACTOR __________________________________________________________________              DATE: _______________________
                                                                                                                     (RE/PM SIGNATURE)**                                      (Pilot Receipt Date)
                                                    ** SIGNATURE SIGNIFIES RECEIPT (NOT APPROVAL) OF PAYMENT                                                                           rev. 05/15/01

								
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