Fill in the invoice number accompanying this report.
Fill in the number of the report you are sending in sequence.
For example: If this is the second report you are submitting,
you send Report No. 2.
This is to be filled in to state the period of time for which you
are reporting. Example: From: April 1, 2005 To: April 30,
Fill in the contract number assigned to your project by TCCD.
Designate the type of contract that has been awarded your
company by TCCD.
Fill in your company’s name, address, telephone number, and
Fill in the date the contract was executed by both you and
Fill in the completion date as written in contract.
Fill in the dollar amount of original contract agreed upon by
you and TCCD.
Current contract modifications, include date modification was
Fill in dollar amount you have received from TCCD to date.
Fill in the dollar amount of the contract minus amount paid to
you by TCCD.
Fill in the percentage of Small M/WBE participation you
committed to obtain in the contract.
Fill in the calculated dollar amount paid to the Small
M/WBE and divided by the dollar amount you
received from TCCD.
Name all the Small M/WBE Subcontractors. (Use
additional sheets as necessary.)
State whether the Subcontractor is a Small M/WBE.
State the work performed by the Small M/WBE
State the amount and date of last payment made to each Small
M/WBE Subcontractor. Submit evidence of payment, i.e.,
cancelled check, check register, etc.
State the committed dollar value to the Small M/WBE
Subcontractor for the duration of the contract and
retainage withheld by Prime Contractor.
Add all amounts paid to each Small M/WBE
Subcontractor to date and retainage released to date.
State dollar amount paid to the Small M/WBE
Subcontractor divided by the amount committed to them.
Fill in how much of this invoice will be paid to each Small