Admin Agreements

							                                                                                                                              AR-00013-01 (7/2007) Rev 2.3
                                                                                                                                             Page1 of 2




                                                                     To Be Completed by Vendor (Submit 1 copy single-sided)
REQUEST FOR PAYMENT
CONSULTANT AGREEMENTS                                                ADMIN MAPS CONTRACT NO.:

STATE OF MINNESOTA                                                   RECS PROJECT NO.:

REAL ESTATE AND CONSTRUCTION SERVICES                                PROJECT NAME:
50 Sherburne Avenue, 309 Administration Building                     LOCATION:
St. Paul, MN 55155
To Be Completed by State                                             CONSULTANT:
Order No.:                      Voucher No.:
                                                                     ADDRESS:


Vendor Invoice No.:                                                  REMIT TO ADDRESS (If different from above):


Payment Amount:                 Date             Initials

                                                                     PHONE:                          E-MAIL:
Original Copy Filed in RECS Project Files
                                                                     FOR WORK COMPLETED FROM: (Billing Period)
Sent to Agency for payment                                                  FROM:                    TO:                INCLUSIVE
                                                                     (check one)       Partial             Final       REQUEST NO.:
Agency                                    Date                       Begin date may not be prior to contract execution date

AGREEMENT SUMMARY: DO NOT FILL IN SHADED AREAS. THESE ARE CALCULATED FIELDS.
   1- Original agreement amount                                                                                                  $                      -

    2-   Supplemental Agreements Approved to Date                            (Nos                                  )             $                      -

    3-   Revised contract amount to date (Total from Column D on Page 2)                                                         $                      -

STATUS OF ACCOUNT:
   4- Value of competed work to date (total from column F on page 2)                                                             $                      -

    5-   Total of estimates previously approved (total from column G on page 2)                                                  $                      -

    6-   Amount due this estimate (total from column H on page 2)                                                                $                      -

                           To Be Completed by State                  CERTIFICATE OF CONSULTANT:
APPROVAL OF RECS PROJECT MANAGER:                                    I (We) certify that all work for which this request for payment is
The work of the project and this estimate have been examined and the made has been completed in full, according to the phases and
amount shown is recommended for payment.                             progress in performance of the work under this Agreement. I (We)
                                                                     also certify that payment has been made for all just claims for
                                                                     labor, material, and services in connection with the work performed
                                                                     on all preceding estimates.

Signature                                         Date
APPROVAL OF RECS PLANNING (final pay request only):
As-built record drawings and specifications received and verified for
completeness.                                                                  Firm Name

                                                                               Signature                                        Date

Signature                                               Date                   Title
To Be Completed by State Prior to Approving Final Pay Requests                 For State Use Only:
         Rec'd Electronic Constr. Documents at end of bid phase                AUDITOR:
         Received As-Builts (3 Sets hard copy)
         Received As-Builts/CADD (3 sets executable files & 1 PDF)
         Received As-Builts Specifications (3 sets hard copy & 1 PDF)
         Owner Training Completed
         Construction Contract Close-out Submittals
         PM has attached P/T evaluation form
         LRL Report Submitted
         Above Items are Not Applicable
                                                                                                                AR-00013-01 (7/2007) Rev 2.3
                                                                                                                               Page2 of 2



ADMIN MAPS CONTRACT NO.:               0
RECS PROJECT NO.:                      0


                             A               B              C            D             E              F                  G              H
                                                                                                                   All Completed Work to
                                                      Contract Amount                  Work Completed                      Date
                                                                                    Previous
Item No.                 Description         Fee          Reimb         Total       Amount        This Period         Amount            %
                                                                        (B+C)                                          (E+F)          (G/B)
           ORIGINAL AGREEMENT
   1       Predesign                               0.00                                    0.00           0.00               0.00
   2       Schematic Design                        0.00                                    0.00           0.00               0.00
   3       Design Development                      0.00                                    0.00           0.00               0.00
   4       Construction Documents                  0.00                                    0.00           0.00               0.00
   5       Bidding                                 0.00                                    0.00           0.00               0.00
   6       Construction                            0.00                                    0.00           0.00               0.00
   7       Contract Closeout                       0.00                                    0.00           0.00               0.00
   8       Reimbursable Expenses                                0.00                       0.00           0.00               0.00
           (Attach invoices/receipts)

   9       Other (Describe Below)                  0.00                                    0.00           0.00               0.00
                                                   0.00                                    0.00           0.00               0.00
                                                   0.00                                    0.00           0.00               0.00
           Total Original Agreement                0.00         0.00         0.00          0.00           0.00               0.00

           SUPPLEMENTAL AGREEMENT NO. 1
  10       Labor (Attach Detail)                   0.00                                    0.00           0.00               0.00
  11       Reimbursable Expenses                                0.00                       0.00           0.00               0.00
  12       Other (Describe)                        0.00                                    0.00           0.00               0.00
                                                   0.00                                    0.00           0.00               0.00
                                                   0.00                                    0.00           0.00               0.00
           Total SA 1                              0.00         0.00         0.00          0.00           0.00               0.00

           SUPPLEMENTAL AGREEMENT NO. 2
  13       Labor (Attach Detail)                   0.00                                    0.00           0.00               0.00
  14       Reimbursable Expenses                                0.00                       0.00           0.00               0.00
  15       Other (Describe)                        0.00                                    0.00           0.00               0.00
                                                   0.00                                    0.00           0.00               0.00
                                                   0.00                                    0.00           0.00               0.00
           Total SA 2                              0.00         0.00         0.00          0.00           0.00               0.00

           SUPPLEMENTAL AGREEMENT NO. 3
  16       Labor (Attach Detail)                   0.00                                    0.00           0.00               0.00
  17       Reimbursable Expenses                                0.00                       0.00           0.00               0.00
  18       Other (Describe)                        0.00                                    0.00           0.00               0.00
                                                   0.00                                    0.00           0.00               0.00
                                                   0.00                                    0.00           0.00               0.00
           Total SA 3                              0.00         0.00         0.00          0.00           0.00               0.00

           SUPPLEMENTAL AGREEMENT NO. 4
  19       Labor (Attach Detail)                   0.00                                    0.00           0.00               0.00
  20       Reimbursable Expenses                                0.00                       0.00           0.00               0.00
  21       Other (Describe)                        0.00                                    0.00           0.00               0.00
                                                   0.00                                    0.00           0.00               0.00
                                                   0.00                                    0.00           0.00               0.00
           Total SA 4                              0.00         0.00         0.00          0.00           0.00               0.00




           Supplemental Agreement Subtotal                                   0.00
           TOTALS                                  0.00         0.00         0.00          0.00           0.00               0.00