<p> CITY OF NEW YORK DEPARTMENT OF DESIGN AND CONSTRUCTION</p><p>CERTIFICATION OF PAYMENT REQUISITION (This certification must accompany each CM/CM Build/Design Build payment requisition)</p><p>Contract No. ______</p><p>Name of Firm ______</p><p>Project Name ______</p><p>FMS ID: ______</p><p>Payment No. ______</p><p>Payment Period______</p><p>I, ______, certify that the information and data contained in the attached payment requisition is true and accurate to the best of my knowledge.</p><p>Specifically, I certify as follows:</p><p>1. With respect to payment for staffing expenses: (a) That the amount requested is based on actual time spent by pre-approved personnel performing services for the project. (b) That the amount requested has been calculated using pre-approved direct salary rates for personnel set forth in the Staffing Plan. Such personnel and rates must be approved in advance by the Commissioner. (c) That those personnel for whom payment is requested have been actually paid the direct salary amounts set forth in this requisition.</p><p>2. That the amount requested for payment for any and all construction work performed by subcontractors is based upon an accurate assessment of the percentage of completion of the required construction work.</p><p>3. That the amount requested for payment for miscellaneous expenses represents actual costs incurred for items pre- authorized by the Commissioner and that the procurement of same conforms to the terms and conditions of the contract.</p><p>4. That the amount requested for payment for additional services represents actual costs incurred for the performance of additional services directed by the Commissioner and that such services have been procured in conformance with applicable contract terms and conditions.</p><p>5. That the basic fee requested is based upon an accurate assessment of the percentage of completion of the construction work, or as stated in the contract.</p><p>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.</p><p>By: ______Sworn to before me this ______day of</p><p>Title: ______(To be signed by an officer or partner of the firm) ______NOTARY cmcert July 10, 1997; rev. 06/04/03</p>