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 EFA CHES 7300-30A (2-98)
Engineering Field Activity Chesapeake
Naval Facilities Engineering Command
CONTRACTORS INVOICE (A/E Contracts)
INVOICE DATE (1) January 1, 1998
INVOICE NUMBER (2) 0001
(3) 123:BLM
FROM: (4) ABC Corporation (POC: Mr. J. D. Doe/757-333-9999)
Remittance Address: (5) ABC Corporation
123 Main Street, Washington, DC
20000
100 Main Street
Dallas, TX 50000
TO:
Code 02AE, Contracts Department
1. Below is a Statement of Performance under Contract (6) N62470-98-C/D-0000
at (Station) Naval Station, Washington, DC
The enclosure provides breakdown of this statement of performance.
$( 7)
A.
Total value of contract through change __________________________________________
61,092.00
( 8)
B.
Percentage of performance complete
35 %
$( 9)
C.
Value of completed performance
21,382.20
Less: Total of prior paid invoices
$(10)
D.
18,382.20
$(11)
E.
Amount of this invoice
3,000.00
(12)
Signature:
Name and Title: (13) J. D. DOE, P. E., President
________________________________________________________________________________________________________________
Government Approval
Date ______________________________
FROM: ___________________________________
TO: ____________________________________________
1.
Payment is recommended as follows:
A.
Amount of work completed to ___________________________
$______________________
B.
Less: Total of prior invoices
$____________________________
C.
Amount of this invoice
$____________________________
D.
Less:
Retention this invoice
$____________________________
(0 to 10% of Item C)
$____________________________
Total retention prior invoices
$____________________________
Other deductions
$____________________________
$______________________
E.
Sub-total
$______________________
F.
Less previous payments
$______________________
G.
Recommended amount for _____________ payment
$______________________
2.
Elapsed contract time ________________%
3.
Signature and Title ________________________________________________________
Technical Representative1
Pursuant to authority vested in me, I certify that this invoice is correct and proper for payment.
DATE ___________________________________ Signature and Title _______________________________________________________
Authorized Certifying Officer1
ACRN
APPN/SUBHEAD
OC
BCN
SA
AAA
TT
PAA
COST CODE
AMOUNT
1
If the ability to certify and authority to recommend are combined in one person, one signature only is necessary; otherwise the Technical Representive will
sign in the space provided.
S/M 0105-LF-003-0205
98
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