Sewer Plant Improvement - 2/28/1964A. Cost of work covered by plans and specifications (From.PHS 2690.2)
$
1
CONTRACTS
2
AMOUNT
3
ADDITIONS-
4
DEDUCTIONS
5
CURRENT AMOUNT
B•Foolsaby Engineering, Inc.
$ 58,10B.25
$
$
$ 58,188.25 '.
c.
-
N. Fees for technical services
4,364.10
D.
- 3,200.35
3,200.35, '
0. Legal costs
200.00
E.
P. Administrative costs
300.00
F.
.
947.95
G. _
/x . / / / /%��r�//�//'
, ' ',��
R.
- - •
H. Total amount of current construction contracts (Lines B thru G)
$ 58,3, a8.25
I. Plus estimated cost of any pending additional work (Describe b lefty)
. .-
e
$ -r
J. Subtotal (Line H plus 1) -
$ 58,188.25
K. Less estimated cost of any pending deductions for omissions (Describe briefly) -
e y,,
$
L. Current estimated cost of work agreed upon and work pending (Line J minus K) _
$ 58,188.25
• 6 _
CLASSIFICATION OF COSTS
7
APPROVED ESTI-
MATED COSTS
(From PHS2690 -2)
8
CURRENT
ESTIMATED
COSrs
9
APPLICANT•S
PAYMENTS
TO DATE
ESTIMATED
VALUE OF WORK-.AIt
IN PLACE
M. Construction 6Caets.
$ 58,189.25
$ 53,188.25
$ 19,250.10
$ 21,389.90
Equipment and materials
-
N. Fees for technical services
4,364.10
4,364.10
- 3,200.35
3,200.35, '
0. Legal costs
200.00
200.00
P. Administrative costs
300.00
300.00
0. Contingency
947.95
947.65
/x . / / / /%��r�//�//'
, ' ',��
R.
S. Totals (Lines M thru R)
$ 64,000.00
$ 64,000.00
$ 22,450.45
$ 24,599.35 , 1
T.
Amount of Grant
$ 19,200.0 -
11. Feder ushare (See instructions) _
%of Column 10, Line S
-,2. ,
$• 7,300.00
V. Less previous payments
$ -
.
W. NET AMOUNT PAYABLE
$ 7,300.00
PMS -2733s
RSV. 8 -63
Form approved by
Comptroller General, U.S.
December 21, 1956
LEGAL NAME AND ADDRESS OF APPLICANT
DATE
City of bound Rock
City Rail. Round Rock, Texas
CONSTRUCTION CONTRACT COSTS
(
PROJECT PROGRESS REPORT AND PAYMENT REQUEST
(See instructions on reverse side)
Deportment of
HEALTH, EDUCATION, AND WELFARE
PUBLIC HEALTH SERVICE
STATUS OF PROJECT
INSTALLMENT
First
PROJECT NO
4,'YC.Tez -242
CERTIFICATION BY APPLICANT 24,589.35
I certify that labor, materials and services in Line 5 of Column 10, having a value of $ , have bean
used Iq ` p�r
s�oject in accordance with approved project agreement. The unpaid pro rata share of the United States is
$ � ,J.W , net amount claimed as noted above, and no previous claim of this amount has been presented to no;
payment made by the United States. o - '
NAME AND TITLE OF APPLICANT's REPRESENTATIVE
(Print or TYPJ
Honoree /El Martin Anderson, Mayor, i
CER J,111$1(340N BY PUBLIC HEALTH SERVICE
I personally inspected this protect on , examined records and found value of work completed as indi- ,
toted above. - - (Date)
V NAME AND TITLE OF INSPECTION OFFICER(Print or
type) F.. A. Gutierrez.
Sanitary Engineer
INSTRUCTIONS
This form .hail b. prepared In quintuplllcate. One copy shall be given to the Applicant, one copy shall
be retained by the regional program office and the original and two copies together with the Approval
of Grant Payment (PHS-2734), shall be forwarded to the reglmal fiscal office.
INSTALLMENT: Enter the number of Installment payment (e.g., 1st, 2d, 3d, or final) covered by the report.
CONSTRUCTION CONTRACT COSTS:
LINE A. Cost of work covered by plans .d specifications. Enter the censMCtlon contract cost as approved in Item F1(.)
of Part 8 of the Offer and Acceptance four (PHS-2690.2).
LINES 8 THRU G. _
COLUMNS 1 & 2. CONTRACTS • AMOUNT. Enter In detail the de•cription and ®aunts of all prime contract.; for
ex.npl•, the general construction contract for $500,000 should be entered: "General Construction" In Column 1 and $500,000 In
Column 2. Any s•perme prim. contracts for installing Intercepting sowers, special equipment, eta should be similarly entered.
COLUMNS 3 & 4. ADDITIONS - DEDUCTIONS. Enter additions and deductions from contract. In Columns 3 and 4
respectively, provided the Applicant and cenlwaetor have agreed on the value and a change order has been Issued by the Applicant
to the contractor. Change orders requiring prior approval of the Pablle Health S.rvIc• should be Included only after such approval
has been given. When approval Is pending, the amount of the change order should be Included under Line 1 or K.
COLUMN 5. CURRENT AMOUNT. Few each Item, enter the total of Columns 2 and 3 minus Calunsn 4.
LINE I. Plus estimated co.l of any pending additional work. Enter the estimated amounts of any proposed additional work,
such as proposed contract modification..
LiNE K. Less estimated cost of any pending deduction. for emissions. Enter the ..timated amounts of my proposed de-
ductions from existing contracts.
STATUS OF PROJECT: -
COLUMN 7. APPROVED ESTIMATED COSTS. Enter the estimated cost shown in Item F1(a) of Part B of the Offer and Ac-
ceptance. tone (PHS•2690 -2) for each Item listed in Column 6.
COLUMN 8. CURRENT ESTIMATED COSTS. Enter the current revised estimated met for each item listed In Column 6.
The purpose of the current estimate 1. to establish a basis for determining whether the Applicant will be In a position to complete
the protect within the amount estimated at the time Pat B was approved. The •stimated cast amounts should b•entered as follows:
LINE Al. Construction Cost.:
Contracts: Enter the amount indicated as the "Current estimated cost of work agreed upon and work pending"
an Lin. L.
Equipment and materials: Enter the current estimated cost of equipment and materials purchased and to be pur-
chased outside of construction contracts. If form account work has been approved, Include the current estimated cost of labor and
materials and other allowable construction casts for such work.
LINE N. Fees: Enter the amount of the original contracts for engln.ering, architectural, inspections, and other
technical services plus my estimated additional allowobl• expenses for fees.
LINE 0. Legal costa: Enter the estimated allowable exp for legal service. In sonnection with the protect.
LINE P. Administrative Costs: Enter the estimated allowable •xp for administrative and Decal services in
connection with the proleet.
LINE Q. Contingency: Amounts entered In Column 8 should reflect by downward or upward °diestment the current
Inc...... or deer.a.es In the original e.timetes far each Item of cost. If It beam.s apparent the available contingency is no
longer needed in Its entire amount, It should b• reduced accordingly. The total of Column 8 will ..teed the total in Column 7 only
when the original contingency has hem exhausted.
■COLUMN 9. APPLICANT'S PAYMENTS TO DATE: Enter, according to cost classification, the amounts of all payments
for allowable costs made by the Applicant as of the date of Inspection.
COLUMN 10. ESTIMATED VALUE OF W9RK IN PLACE, SERVICES AND EQUIPMENT: This column will reflect, dr
Ina to teat els..7Healon, the •sNeat•d value of th•.wo,k perfumed, services rendered, and materials and •goipm.nt delivered as
of the date of the Inspection. (As used here, ••vela•" means the cost to date of material and equipment delivered and services
rendered. With respect to construction contracts, "value" mom. the •stimeted worth of completed work based an the turns and
amount of the construction contracts.) Thi• estimate will be based upon a physical inspection made by the Inspector and will
represent the appraised value of the portion of the prefect and the allowable costs in which th• Federal Government will partici-
pate.
LINE M. Construction Cosh
Contract.: Enter the value of work performed, materials and equipment in pl.e• or delivered to rho site under
canstru.Non conhocts.
Equipment and materials: Enter the value of equipment and materials, purchased .outdo of construction con-
tracts which have been installed or delivered to the sit.. If force account week has been approved, include the arrant allowable
coats of labor and materials and other allowable constnrcNan costs for such work.
LINE N. Feast Enter the amount earned to the data of Inspection under the terms of c.nnacta for such services.
LINE 0. Legal C.st. Enter allowable oats incurred to date.
LINE P. Administrative Costs: Enter ellewebl. coat. Incurred to date.
LINE U. Federal share: The percentage for computing the Federal share may change for each payment: Except for the
final Installment, the percentage used should be the smaller of either (1) the percentage rounded downward to the nearest whole
number, which the amount of the grant bears to the total current estimmed,cost of the prefect (Line 5, Column 8), to (2) the
percentage of Federal participation on which the original grant was computed. Except for the final installment, the Federal share
shall be rounded downward to the nearest ane hundred dollars. The Federal shore when calculating the final - Installment shall
not exceed (_hg smaller of (1) the amount of.the grant or (2) the actual allowable audited coats, excluding cents, multiplied by the
percentage of Federal participation on which the grant was computed and rounded downward to the nearest whole dollar. Cents
should be dropped iron the computed Federal cost on lines T, U, and W and In the Certification by the Applicant (See Part 43-
14, Health Grants Manual). _
CERTIFICATION BY APPLICATION: This eertiflcatien must be signed by MI authorised representative of the Applicant.
CERTIFICATION BY PUBLIC HEALTH SERVICE* TMs certification must be signed by the representative of the Public Health
Service who mad. tine Inspection. - y
PHS -2733 (BACK) -