Blank DCAS payment authorization form, Nov 1999

NYC 9/11 Public Portal Document

DEPARTMENT OF CITYWIDE ADMINnSl RATI Payment Routing/Certification Records'^?? ED Part I; Payment Data ^'^7 [ ] FMC [iTdRES [ ] OEC

1. Contract # CP # Capisid #P IN | 3? 2. Project Name/Description O ,J VJ Cor Vg ______ 3. RE/PM Name \ / 1 Telephone # 4. Contractor/ConsultantA^endor_________________________________________________ 5. Contract Type (Check all that apply) [ ] Capital [ ] Expense [ ] Construction [ ] Lump Sum [ ] Unit Price [ ] Requirements [ ] CM Build/Design Build [ ] Open Market Order [ ] Consultant [ ] Other (please state)____________________________ _ _____________ 6. Payment .# S" Amount Due $ Pay Per._______ To_______ 7. Payment Type (Check all that apply) [ ] Partial [ ] Cha^e Order [] Task/Work Order [ ] Substantial [ ] Final [ ] Retainage [ ] Bond Substance [ ] Article 17 [ ] Other (please state)________________________________________________________

Part II: Processing Dates

1. In From ContractorRE/PM RE/PM Sign Off 2. Budget In Date Budget Out Date Budget Rejection Date / 3. Reason for BudgetRty ection_________________ £________________________________ 4. FMC/DRES/OEC Out Date FMC/DRES/OEC Rejection Date 5. Reason for FMC/DRES/OEC Rejection 6. EAO In DateYO^^K/^ 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 III; Required Signatures/Approvals

1. RE/PM Signoff p/-/ (DCAS Employees Only) . Print Name ^nature Date

2. Budget Reviewer a Print Name f Signature

3. EAO Auditor Print Name Signature Date

4. Audit’s Auditor Print Name Signature Date

NYC-WTC_000171597