Cumulative Monthly Payment Statement - New York State Office Of Parks, Recreation And Historic Preservation

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New York State Office of Parks, Recreation and Historic Preservation
Bureau of Affirmative Action & Equal Opportunity
Albany, New York 12238
(518) 486-2921
CUMULATIVE MONTHLY PAYMENT STATEMENT
INSTRUCTIONS: As a condition of the contract awarded this form is to be properly
TH
completed by the primary contractor on a monthly basis indicating ALL sub contractors that will be utilized on the project.
S
10
UBMISSION OF THIS FORM SHOULD BE SENT BY THE
DAY OF EACH
’
MWBE
.
MONTH FOR THE PRECEDING MONTH
S ACTIVITY AS EVIDENCE TOWARDS ACHIEVEMENT OF THE
GOALS ASSIGNED TO THE CONTRACT
MWBE Goals Assigned to the Contract:
Region:
(including any field order allowance)
$
Total Contract Value:
MBE
%
WBE
%
Start
Contractor’s Name:
Contract Number:
Date:
□
□
Are you a NYS MWBE Certified by the NYS Empire State Development Corp?
Yes
No
Contract
Completion
Description:
Date:
Address:
Telephone
E-mail
Contract
Number:
Address:
Location:
Federal ID
SFS Vendor
Reporting
.
.
Statement #
.
No.:
ID:
Period:
Month/Day
Year
Total Dollar
Total
% of
Certified M/WBE Sub Contractors/ Suppliers
Identification
Payments This
Designation
Value of
Payments to
Contract
(Please check all that apply)
Name, Address, Telephone No., E-mail Address,
Numbers
Month Only
Paid Out
Contract
Date
□
□
MBE
WBE
Federal ID:
□
□
DBE
NON-MWBE
SFS Vendor ID:
□
□
□
Supplier
Sub
No Payment This Month
□
□
MBE
WBE
Federal ID:
□
□
DBE
NON-MWBE
SFS Vendor ID:
□
□
□
Supplier
Sub
No Payment This Month
□
□
MBE
WBE
Federal ID:
□
□
DBE
NON-MWBE
SFS Vendor ID:
□
□
□
Supplier
Sub
No Payment This Month
□
□
MBE
WBE
Federal ID:
□
□
DBE
NON-MWBE
SFS Vendor ID:
□
□
□
Supplier
Sub
No Payment This Month
DECLARATION: Under penalty of perjury, I attest as follows: I certify that I am a
% of
representative of the above-stated Contractor and that I am authorized to make this
DOLLAR
FOR NYS OPRHP USE ONLY:
TOTAL
DECLARATION on behalf of the Contractor. All information stated on this Payment
VALUE
AWARD
Statement is true and correct. Payments stated on this form were made by the Contractor
Total value of contract for services and/or supplies assigned to
for work actually performed by the subcontractor(s) and/or supplier(s) listed, including
MBEs:
MWBEs. The Contractor has complied with all contract provisions and laws, including
those related to use of MWBEs, equal opportunity and affirmative action.
Total value of contract for services and/or supplies assigned to
WBEs:
Total overall dollar value and percentage of contract assigned to
Signature of Contractor
Date
MWBEs
Print Name and Title
(Revised August 2013)

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