CITY OF NEW YORK

DEPARTMENT OF DESIGN AND CONSTRUCTION

DIVISION OF STRUCTURES

SUBCONTRACT SUMMARY FORM

(This form is to be completed by the CM for all construction subcontracts on CM Build & CM Design Build contracts and included in all requests for payment. For multi-site contracts, provide sub-totals for each site. For Requirement Contracts, complete one form for each Task Order.)

CONTRACT REG. NO. ______TASK ORDER NO. ______FMS ID # (S) ______PAYMENT NO. ______

WORK PERIOD: FROM ______TO ______ORIGINAL CONSTRUCTION SERVICE ALLOWANCE: $ ______CURRENT CONSTRUCTION SERVICE ALLOWANCE: $ ______

A / B / C / D / E / F / G / H / I / J / K / L / M
SITE ID # / TRADE / SUB
CONTRACTOR / ORIGINAL SUBCONTRACT AMT / APPROVED SUBCONTRACT CHANGE ORDERS / TOTAL SUBCONTRACT AMT (D + E) / WORK COMPLETED / TOTAL COMPLETED TO DATE (G + H) / %
(I\F) / TOTAL RETAINAGE
TO DATE / TOTAL TO DATE
(I - J) / PAID TO DATE / CURRENT AMOUNT DUE
(K - L)
FROM PREVIOUS APPLICATIONS
(G + H) / THIS PERIOD
TOTAL THIS SHEET / $ / $ / $ / $ / $ / $ / X / $ / $ / $ / $
GRAND TOTAL / $ / $ / $ / $ / $ / $ / X / $ / $ / $ / $

I certify that the information above is complete and accurate. I understand that the submission of fraudulent information in a requisition for payment may, at a minimum, result in the termination of the contract for cause and may render the firm not responsible for the award of future contracts from the City of New York.

BY:

______

(Print CM Company name) (Print CM Representatives name) (Title) (Signature) (Date)

Sheet ____of ______rev. 01/15/98