Co nstruction Payout Request
Th e Archdiocese of Chicago
Facilities & Construction Department
P.O. Box 1979
Chicago, IL 60690
Date
PART A
Vendor Name
Address
State
City
Contracted for
--
Zip
type of work)
Parish of
(Name and Address)
Original Contract Price
1$
Extra Work
2 $ EXE CUTED CHANGEORDERAD DI TIONS
Deductions
C UTE D CHANGEORDER DEDUC TIONS
J$ EXE
FROM:
Adjusted Contract Price
4$ TOTAL LINE 1 PLUS 2 MINUS 3
THRU:
Total Work Completed to Date
5 $ TOTAL WORK COMP LETED TO DATE
. 0 % Retained
ORI GINAL CONTRAC T AMOUNT
INVOICED WORK PERFORMED
DATES WORK PERFORMED
FOR THI S PAYMENT ONLY "
6 $ RENTEN TION WITHHELD (I F ANY)
Sub-Total
7 $ TOTAL LINE 5 MINUS 6
Total Previous Payments
8$ TOTAL PREVIOUS PAYMEN T S
9$ TOTAL LINE 7 MINUS 8
NO PAYOUT WILLBE MADE UNLESS THIS FORM
This Payment"
IS ACCOMPANIEDBY A WAIVER OF LIEN
PABTB
Source of Funds
Building Fund
Parish ID#
$
General Savings
Millennium Savings
CD (Maturity Date) __/__/_
Endowment (Earnings Only)
Loan
$
$
Capital Grant
Noise Abatement Grant
Major Gift Capital Grant
Public School Lease
$
Big Shoulders Capital Grant
Millennium Capital Grant
other�--���-�--
-
�mo�nt
Account Number
$
$
FUNDING APPROVAL
$
$
$
$
Pastor
$
Date
$
$
*
TOTAL
$
*Amounts should
equal REQUEST
each other
DIRECTIONS
FOR PAY
PART
A Note:The payment instructions must agree with the approved Capital Project Summary Form funding requirement
Please
REV 5122016
• Insert date and fill out vendor information completely
• Fill out type of work
• Enter parish name and location/identification
• Fill out dollar figures:
CONTRACT INFORMATION (LINES 1-4 indicated above)
o Line 1 = Original contract amount
o Line 2 = Executed change order additions (if any)
o Line 3 = Executed change order deductions (if any)
o Line 4 = Adjusted Contract Price - Original plus/minus CO's
PAYMENT INFORMATION (LINES 5-9 indicated above)
o Line 5 = TOTAL work completed to date (this invoice amount plus any previously invoiced amounts if any)
o Line 6 = Amount retained (if any)
o Line 7 = Subtotal is Total work completed less amount retained
o Line 8 = TOTAL previous payment (this number must match amount paid this vendor to date on Crystal)
o Line 9 = This Payment is Subtotal minus previous paid (if any) and must match invoice & waiver
• Work performed dates should reflect the work performed for this invoice ONLY - not the entire project duration.
PART B
• Pastor to indicate on the proper line the account and amount from which to pay and sign/date in Funding Approval box.
NOTE: BOTTOM LINE OF PART A MUST BE EQUAL TO THE BOTTOM LINE OF PART B
.
I