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JOB NUMBER:

CONTRACTOR:

REPORT NO.:

FAP NUMBER:

CONTRACT AMOUNT:

EST. END DATE:

RESIDENT ENGINEER:

DBE GOAL AMOUNT:

DBE GOAL %:

FIRM

DATE

AMOUNT

AMOUNT

(check

PAID

PAID THIS

PAID TO

here)

PERIOD

DATE

SECTION 107

2003 SPECIFICATIONS

DBE PRIME CONTRACTOR PAYMENT LOG TO DBE and NON-DBE FIRMS

RETAINAGE

HELD

PAID

NAME OF FIRM (any firm providing subcontracting work or services on project)

DBE

The Contractor certifies that the above amounts have been paid to those listed firms and that documentation of these payments is available for inspection upon request.

Authorized Signature Typed/Printed Name Title

Date

Must be received from Contractor within 30 calendar days following the end of the estimate period..

DEPARTMENT USE ONLY Reviewed By

Date

Rev. 4-10-00

Figure 107-15

ARKANSAS STATE HIGHWAY AND TRANSPORTATION DEPARTMENT Page 100-75

7-01-03

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