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1.   Invoice No.

     Fill in the invoice number accompanying this report.

2.   Report No.

     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.

3.   Reporting Period

     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,

     2005.

4.   TCCD Contract Number

     Fill in the contract number assigned to your project by TCCD.

5.   Type of Contract

     Designate the type of contract that has been awarded your

     company by TCCD.

6.   Contractor’s Business Name, Address, Telephone Number  

     and E-mail Address

     Fill in your company’s name, address, telephone number, and   

     e-mail address.

7.   Date of Contract Award

     Fill in the date the contract was executed by both you and

     TCCD.

8.   Scheduled Date of Completion

     Fill in the completion date as written in contract.

9.   Original Contract Amount

     Fill in the dollar amount of original contract agreed upon by  

     you and TCCD.

10. Current Amended Contract Amount & Date

     Current contract modifications, include date modification was

     executed.

11.  Total Amount Received to Date

      Fill in dollar amount you have received from TCCD to date.

12.  Total Amount Owed

      Fill in the dollar amount of the contract minus amount paid to

      you by TCCD.

12a. Current invoice amount

13.  Committed Small M/WBE Participation

      Fill in the percentage of Small M/WBE participation you

      committed to obtain in the contract.

14. Instructions for Calculation of Small M/WBE Percentage  

15.  Actual Small M/WBE Percent Paid to Date

      Fill in the calculated dollar amount paid to the Small

      M/WBE and divided by the dollar amount you

      received from TCCD.

16.  Name of Subcontractors

      Name all the Small M/WBE Subcontractors. (Use

      additional sheets as necessary.)

17.  Small M/WBE

      State whether the Subcontractor is a Small M/WBE.

18.  Description of Work

      State the work performed by the Small M/WBE

      Subcontractor.

19.  Amount and Date of Last Payment

      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.

20.  Subcontract Value (Dollars)

      State the committed dollar value to the Small M/WBE

      Subcontractor for the duration of the contract and

      retainage withheld by Prime Contractor.

21.  Total Amount Paid to Date (Dollars)

      Add all amounts paid to each Small M/WBE  

      Subcontractor to date and retainage released to date.

22.  Percent of Earned Progress to Date

      State dollar amount paid to the Small M/WBE

      Subcontractor divided by the amount committed to them.

23.  Amount of This Invoice Allocated to the Subcontractor

      Fill in how much of this invoice will be paid to each Small

      M/WBE Subcontractor.

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