Blank DCAS payment authorization form, Nov 1999

NYC 9/11 Public Portal Document

DEPARTMENT OF CITYWIDE ADMINISTRATIVE SERVICES Payment Routing/Certification Records

Part I; Payment Data [ ] FMC [TYdRES [ ] OEC

1. Contract # h' S CP # Capisid #)Pk\) C 2. Project Name/Description ,0\A? OtI J _______ 3. RE/PMName Telephone# 4. Contractor/Consultant/Vendor_________________________________________________ 5. Contract Type ( Check all that apply) [ ] Capital [ ] Expense [ ] Construction [ ] Lump Sum [ ] Unit Price [ ] Requirements [ ] CM Build/Design Build [ ] Open Markel Order [ ] Consultant [ ] Other (please state)___________________________________________ 6. Payment .# S" Amount Due $ Pay Per._______ To_______ 7. Payment Type (Check all that apply) [ ] Partial [ ] Ch^e Order [ ] Task/Work Order [] Substantial [] Final [ ] Retainage [] Bond Substance [] Article 17 [ ] Other (please state)________________________________________________________

Part II: Processing Dates 1. In From Contractor Jj ZRE/PM In RE/PM Sign

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/DRJSS/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 III; Required Signatures/Approvals

1. RE/PMSignoff (DCAS Employees Only) ft/\ ' ,yi Print Name _____________ Signature Date

2. Budget Reviewer Print Name Signature Date

3. EAO Auditor Print Name Signature Date

4. Audit’s Auditor Print Name Signature Date

NYC-WTC_000171604