Payment data form, Jan 2000

NYC 9/11 Public Portal Document

DEPARTMENT OF CITYWIDE ADMINISTRATIVE SERVICES Payment Routing/Certification Records

Part I: PaVinent Data [ ] FMC [ufDRES [ ] OEC

1. Contract #CP # capisid /s 2. Project Name/Description (^^fl/1 y _____ 3. RE/PM Name Telephone # ^6^-. 4. Contractor/Consultant/Vendor________._________________________________________ 5. Contract Type (Check all that apply) fx/Capital [ ] Expense [ ] Construction [ ] Lump Sum [ ] Unit Price [ ] Requirements [ ] CM Build/Design Buil^ [ ] Open Mai'ket Order [ ] Consultant [ ] Otlier (please state)________________ __________________________ 6. Payment .# .Amount Due $ Pay Per. To 7. Payment Type (Check all that apply) [*}Tartial [ ] Change Order [ ] Task/Work Order I ] Substantial [] Final [JRetainage [] Bond Substance [] Article 17 I ] Other (please state)_____________________________________________________

Part n : Processing Dates 1. In From Contractor^y4^y^ RE/PM In RE/PM Sign Off 2. Budget In Date Budget Out Date Budget Rejection Date 3. Reason for Budget Rejection 4. FMC/DRES/OEC Out Date FMC/DRES/OEC Rejection Date 5. Reason for FMC/DRES/OEC Rejection 6. EAO In Date EAO Out Date EAO Rejection Date 7. EAO’s Reason for Rejection 8. Audit In Date Audit Out Date Audit’s Rejection Date 9. Audit’s Reason for Rejection

Part HI: Required Signatures/Al^rd^als

1. RE/PM Signoff (DCAS Employees Only) Print Name Signature Date

2. Budget Reviewer Print Name Signature Date

3. E AO Auditor Print Name Signature Date

4. Audit’s Auditor Print Name Signature Date

NYC-WTC_000171535