Cumulative Monthly Payment Statement - New York State Office Of Parks, Recreation And Historic Preservation Page 2

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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 EXTRA PAGES
INSTRUCTIONS: As a condition of the contract award
this form is to be properly completed by the primary contractor on a monthly basis indicating ALL sub contractors that will be utilized on the project.
S
UBMISSION OF THIS FORM SHOULD BE SENT BY
TH
10
’
MWBE
’
.
THE
DAY OF EACH MONTH FOR THE PRECEDING MONTH
S ACTIVITY AS EVIDENCE TOWARDS ACHIEVEMENT OF THE
GOALS
ASSIGNED TO THE CONTRACT
.
.
Region:
Contract Number:
Total
% of
Certified M/WBE Sub Contractors/ Suppliers
Identification
Total Contact
Payments This
Designation
Payments
Contract
(Please check all that apply)
Name, Address, Telephone No., E-mail Address,
Numbers
Dollar Value
Month Only
Paid Out
to Date
Federal ID:
□
□
MBE
WBE
□
□
DBE
NON-MWBE
SFS Vendor ID:
□
□
Supplier
Sub
□
No Payment This Month
Federal ID:
□
□
MBE
WBE
□
□
DBE
NON-MWBE
SFS Vendor ID:
□
□
Supplier
Sub
□
No Payment This Month
Federal ID:
□
□
MBE
WBE
□
□
DBE
NON-MWBE
SFS Vendor ID:
□
□
Supplier
Sub
□
No Payment This Month
Federal ID:
□
□
MBE
WBE
□
□
DBE
NON-MWBE
SFS Vendor ID:
□
□
Supplier
Sub
□
No Payment This Month
Federal ID:
□
□
MBE
WBE
□
□
DBE
NON-MWBE
SFS Vendor ID:
□
□
Supplier
Sub
□
No Payment This Month
Federal ID:
□
□
MBE
WBE
□
□
DBE
NON-MWBE
SFS Vendor ID:
□
□
Supplier
Sub
□
No Payment This Month
Federal ID:
□
□
MBE
WBE
□
□
DBE
NON-MWBE
□
□
Supplier
Sub
SFS Vendor ID:
□
No Payment This Month
Federal ID:
□
□
MBE
WBE
□
□
DBE
NON-MWBE
SFS Vendor ID:
□
□
Supplier
Sub
□
No Payment This Month
(
Revised August 2013)

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