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Instructions
Headings. Enier all identifying data required. Periodic estimates must be Certifications. The certification of the contractor includes the analysis of
numbered in sequence beginning with the number 1. amounts used fo determine the net balance due. In the first paragraph, enter
. a if a . the name of the Public Housing Agency, the contractor, and the date of the
Columns 1 and 2. The'iteny Number'and "Description of Item’ must contract. Enter the calculations used in arriving at the “Balance Due This
correspend {fo the number and descriptive title assigned to each principal Payment’ on lines 1 through 16,
division of work in the "Schedule of Amounts for Contract Payments", form
HUD-51000. Enter the contractors name and signature in the certification following line 16.
Column 3. Enier the accumulated value of each principal division of work The latter portion of this certification relating to payment of legal rates of
completed as of the closing date of the periodic estimate. Enter the total in wages, is required by the contract before any payment may be made.
the space provided. However, if the contractor does not choose to certify on behalf of his/her
subcontractors to wage payments made by them, he/she may modify the
language to cover only himself /nerself and attach a list of all subcontractors
who employed labor on the site during the period covered by the Periodic
Estimate, together with the individual certifications of each.
Certification of the Contractor or Duly Authorized Representative
According to the best of my knowledge and belief, | certify that all items and amounts shown on the other side of this form are correct; that all
work has been performed and material supplied in full accordance with the items and conditions of the contract between the (name of owner)
and (contractor)
dated (mmidd/yyyy) and duly authorized deviations, substitutions, alterations, and additions; that ihe following is a
true and correct statement of the Contract Account up to and including the last day of the period covered by this estimate, and that no part of the “Balance Due
This Payment" has been received.
1. Original Contract Amount $.
Approved Change Orders:
2, Additions (Total from Col. 3, form HUD-51002) $ a
3. Deductions (Total from Col. 5, form HUD-51002) $e (nef) $_
4. Current Adjusted Contract Amount (line 1 plus or minus net) $.
Computation of Balance Due this Payment.
5. Value of Original Contract work compieted te date (from other side of this form) §.
Completed Under Approved Change Orders
8. Additions (from Col. 4, form HUD-51002) §
7. Deductions (from Col.5, form HUD-51002) $. (net) $
8. Total Value of Work in Place (line 5 plus or minus net line 7) $
9. Less: Reiainage, ss % $
10. Net amount earned to date (line 8 less line 9) $.
11. Less: Previously earned (line 10, last Periodic Estimate) §
42, Net amount due, work in place (line 10 less line 11) $
Value of Materials Properly Stored
13. At close of this period (from form HUD-51004) $.
14, Less: Allowed last period 5.
415. Increase (decrease) from amount allowed last period $e
16. Balance Due This Payment S$
| further certify that ail Just and lawful bills against the undersigned and his/her subcontractors for labor, material, and equipment employed in the performance
of this contract have been paid in full in accordance with the terms and conditions of this contract, and that the undersigned and his/her subcontractors have
complied with, or that there is an honest dispute with respect to, the labor provisions of this contract.
Name of Contractor Signature of Authorized Representative Titi Date (mmiddiyyyy}
Certificate of Authorized Project Representative and of Contracting Officer
Each of us ceritfies that he/she has checked and verified this Periodic Estimate No. ; that to the best of his/her knowledge and belief itis a true
statement of the value of work performed and maierial supplied by the contractor; that all work and material included in this estimate has been inspected by him/her
or by his/her authorized assistants; and that such work has been performed or supplied in full accordance with the drawings and specifications, all applicable
accessibility requirements (including Section 504 and Title Il of the Americans with Disabilities Act; and the Fair Housing Act and Title Il of the Americans with Disa
bilities Act, if applicable),the terms and conditions of the contract, and duly authorized deviations, substitutions, alterations, and additions. all of which have been
duly approved.
We, therefore, approve as the "Balance Due this Payment" the amount of $
Authorized Project Representative | Date (mmiddlyyyy) _/ Contracting Officer Date (mmiddiyyyy)
J certify the information on this form and in any accompanying documentation is true and accurate. | acknowledge making, presenting, or submitting a false, fictitious, or fraudulent statement, rep-
resentation, or certtication may result in criminal, civil, and/or administrative sanctions, including fines, penelties, and confinement for up to S years, (18 U.S.C. §§ 287, 1001 and 31 U.S.C. 83728
d
Previous editions are obsolete form HUD-51001 (1/2014)Jump to an indexed page (88 of 88)