Form Hud-51001 - Periodic Estimate For Partial Payment Page 2

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Instructions

Certifications. The certification of the contractor includes the analysis of

Headings. Enter all identifying data required. Periodic estimates must

amounts used to determine the net balance due. In the first paragraph, enter

be numbered in sequence beginning with the number 1.

the name of the Public Housing Agency, the contractor, and the date of the

Columns 1 and 2. The"Item Number"and "Description of Item" must

contract. Enter the calculations used in arriving at the "Balance Due This

correspond to 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",

Enter the contractor's name and signature in the certification following line 16.

form HUD-51000.

The latter portion of this certification relating to payment of legal rates of

Column 3. Enter the accumulated value of each principal division of

wages, is required by the contract before any payment may be made.

work completed as of the closing date of the periodic estimate. Enter the

However, if the contractor does not choose to certify on behalf of his/her

total in the space provided.

subcontractors to wage payments made by them, he/she may modify the

language to cover only himself /herself 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, I 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 (mm/dd/yyyy) _________________________________, and duly authorized deviations, substitutions, alterations, and additions; that the 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)

$___________________

3. Deductions (Total from Col. 5, form HUD-51002)

$___________________

(net) $__________________

4. Current Adjusted Contract Amount (line 1 plus or minus net)

$______________________

Computation of Balance Due this Payment

5. Value of Original Contract work completed to date (from other side of this form)

$______________________

Completed Under Approved Change Orders

6. 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: Retainage, __________ %

$___________________

10. Net amount earned to date (line 8 less line 9)

$__________________

11. Less: Previously earned (line 10, last Periodic Estimate)

$__________________

12. 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

$__________________

15. Increase (decrease) from amount allowed last period

$__________________

16. Balance Due This Payment

$______________________

I further certify that all 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

Title

Date (mm/dd/yyyy)

Certificate of Authorized Project Representative and of Contracting Officer

Each of us certifies that he/she has checked and verified this Periodic Estimate No. __________; that to the best of his/her knowledge and belief it is a true

statement of the value of work performed and material 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, 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 (mm/dd/yyyy)

Contracting Officer

Date (mm/dd/yyyy)

Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802)

Previous editions are obsolete

ref. Handbooks 7417.1 & 7450.1

form HUD-51001 (3/92)