Client Name ??????

Contractor's Payment Certificate

Interim Advance Payment Interim Progress Payment Final Pay and Release of Retention Interim Exchange of Retention

CONTRACT NO.: CONSULTANT CONTRACTOR PROJECT TITLE Original Contract Value Provisional Sums Approved Omission Variation Orders Approved Addition Variation Orders Revised Contract Value $ $ $ $ $

Contractor's Payment Certificate No.: Certificate Date: Valuation Date :

CUMULATIVE To Date (SR)

CUMULATIVE previous (SR)

THIS PAYMENT (SR)

Executed Against Original Contract

Value of Works executed against Lump Sum Break Down of $ Value of Works executed against Provisional Sums Material on site Sub total

Gross Certified Against Original Contract Executed Against Change Orders

Value of Works executed against Change Order

TOTAL GROSS CERTIFIED

RETENTION RETAINED RELEASED

TOTAL NET CERTIFIED

ADVANCE PAYMENT ADVANCE PAYMENT RECOVERY Deductions, Penalties and / or other Adjustments On Hold Total Deductions / On Hold Amounts

AMOUNT CERTIFIED THIS PAYMENT CERTIFICATE

Submitted by Contractor:

Stamp:

Project Manager Reviewed by Engineer: Stamp:

Resident Engineer Certified for Payment by Program Manager:

Project Manager Approved for Payment by Client:

Commercial Manager

Project Executive

Engineering Dept. Manager

Client - General Manager

IPC R.00