Fillable Printable Application For Partial Payment

Application For Partial Payment

PREVIOUSLY

SHIPPED AND

INVOICED

APPLICATION FOR PARTIAL PAYMENT

OMB Control Number: 9000-0012

Expiration Date: 2/29/2020

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 USC § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You

do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 9000-0012.

We estimate that it will take 2.5 hours to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate, including suggestions for

reducing this burden, or any other aspects of this collection of information to: U.S. General Services Administration, Regulatory Secretariat Division (M1V1CB), 1800 F Street, NW,

Washington, DC 20405.

For use by Prime Contractor or Subcontractor under contracts terminated for the convenience of the Government

THIS APPLICATION APPLIES TO (Check one)

A PRIME CONTRACT WITH

THE GOVERNMENT

SUBCONTRACT OR

PURCHASE ORDER

SUBCONTRACT OR PURCHASE ORDER NUMBER(S)

APPLICANT

STREET ADDRESS

CITY AND STATE (Include ZIP Code)

NAME OF GOVERNMENT AGENCY

CONTRACTOR WHO SENT NOTICE OF TERMINATION

NAME

ADDRESS (Include ZIP Code)

IF CONTRACTOR HAS GUARANTEED LOANS OR HAS ASSIGNED

MONEYS DUE UNDER THE CONTRACT, GIVE THE FOLLOWING:

NAME AND ADDRESS OF FINANCING INSTITUTION (Include ZIP Code)

NAME AND ADDRESS OF GUARANTOR (Include ZIP Code)

NAME AND ADDRESS OF ASSIGNEE (Include ZIP Code)

GOVERNMENT PRIME CONTRACT NUMBER

CONTRACTOR'S REFERENCE NUMBER

EFFECTIVE DATE OF TERMINATION DATE OF THIS APPLICATION

AMOUNT REQUESTED APPLICATION NUMBER UNDER THIS

TERMINATION

SECTION I - STATUS OF CONTRACT OR ORDER AT EFFECTIVE DATE OF TERMINATION

PRODUCTS COVERED BY TERMINATED

CONTRACT OR PURCHASE ORDER

FINISHED

UNFINISHED OR NOT

COMMENCED

TOTAL

COVERED BY

CONTRACT

OR ORDER

QUANTITY

(b)(a) (c) (d) (e) (f) (g)

QUANTITY

ON HAND

PAYMENT TO BE

RECEIVED

THROUGH

INVOICING

INCLUDED IN

THIS

APPLICATION

TO BE

COMPLETED

NOT TO BE

COMPLETED

SECTION II - APPLICANT'S OWN TERMINATION CHARGES

(Exclusive of its Subcontractors' Charges)

SETTLEMENT

ATTACHED

PREVIOUSLY SUBMITTED

ITEM

NUMBER

(a)

(b)

(c)

(d)

(e)

10.

CHARGES AS LISTED IN SETTLEMENT PROPOSAL

AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition is usable

STANDARD FORM 1440 (REV. 1/1995)

Prescribed by GSA-FAR (48 CFR) 53.249(a)(7)

ACCEPTABLE FURNISHED PRODUCT (at contract price)

WORK-IN-PROCESS

RAW MATERIALS, PURCHASED PARTS, AND SUPPLIES

GENERAL AND ADMINISTRATIVE EXPENSES

TOTAL (Sum of lines 1, 2, 3, and 4)

SPECIAL TOOLING AND SPECIAL TEST EQUIPMENT

OTHER COSTS

SETTLEMENT EXPENSES

TOTAL (Sum of lines 5, 6, 7, and 8)

SUBCONTRACTOR SETTLEMENTS APPROVED BY CONTRACTING OFFICER OR SETTLED

UNDER A DELEGATION OF AUTHORITY AND PAID BY APPLICANT

UNLIQUIDATED PARTIAL, PROGRESS, AND ADVANCE PAYMENTS RECEIVED

11. AMOUNT RECEIVED

DISPOSAL AND OTHER CREDITS

TOTAL (Sum of lines a and b)

AMOUNT OF PARTIAL PAYMENT REQUESTED

TOTAL (Sum of lines c and d)

(Where the space provided for any information is insufficient, continue on a separate sheet.)

STANDARD FORM 1440

(REV. 1/1995) BACK

SECTION III - AGREEMENT OF APPLICANT

IN CONSIDERATION OF PARTIAL PAYMENT THAT MAY BE MADE, THE APPLICANT AGREES AS FOLLOWS:

(a) Repayment of Excess. If any partial payment made to the Contractor is in excess of the amount finally determined to be due on its termination settlement proposal or claim, the

Contractor shall repay the excess to the Government upon demand together with interest at the rate established by the Secretary of the Treasury under 50 U.S.C. (app.) 1215(b)(2).

Interest shall be computed for the period from the date of the excess payment to the date the excess is repaid. Interest shall not be charged however, for any (1) excess payment

due to a reduction in the Contractor's proposal or claim because of retention or other disposition of termination inventory, until 10 days after the date of the retention or disposition,

or any later date determined by the Contracting Officer because of the circumstances, or for (2) overpayment under cost-reimbursement research and development contracts

(without profit or fee to the Contractor) if the overpayments are repaid to the Government within 30 days after demand.

(b) Prompt Settlement of Proposal. The applicant will make every effort to expedite final settlement of the termination settlement proposal and any proposals of its subcontractors.

(c) Disposal and Retention of Inventory. The applicant shall, within 10 days, notify the Contracting Officer whenever the proceeds received from the disposal of termination

inventory, when added to the cost or agreed value of inventory retained by the applicant, exceeds the amount of its charges (Section II, Line 9) and the amount of such credits has

not been included on Section II, Line b (Disposal and Other Credits).

SECTION IV - CERTIFICATE OF APPLICANT

dated

, is not less than $

number

with

the amounts received are set forth above; and that I have not assigned any moneys payable under this contract, except as set forth above.

SECTION VI - RECOMMENDATION OF OTHER REVIEWING CONTRACTORS

CONTRACTOR DATE

IDENTIFICATION OF

YOUR CONTRACT

SIGNATURE OF OFFICER, PARTNER,

OR OWNER

; that, to the best of my knowledge,

(From Section II, Line 9)

NAME OF APPLICANT

I certify that the amount of charges (exclusive of subcontractors' charges) due as of the date of this application and allocable to the terminated portion of contract

BY (Signature of authorized official)

TITLE DATE

BY (Signature of authorized official)

TITLE DATE

SECTION V - RECOMMENDATION OF FIRST REVIEWING CONTRACTOR

The undersigned states that it has examined this application and has considered the applicant's general reputation. It has no reason to doubt the accuracy of the

information contained in this application or that amount certified by the applicant as due will constitute a proper charge to be included in the undersigned's termination

The undersigned agrees that it will promptly pay over to the applicant or credit against amounts owing from the applicant any amount received for the benefit of the

applicant under this application, and that it will repay to the Government on demand any amount not so paid or credited.

Each of the undersigned states that it has no reason to doubt that the amount of the partial payment requested, and recommended above is due the applicant will

constitute a proper charge in the termination settlement proposal of the undersigned.

Each of the undersigned agrees that it will promptly pay over to its immediate subcontractor or credit against amounts owing from such subcontractor any amount

received for the benefit of the applicant under this application, and that it will repay to the Government on demand any amount not so paid or credited.

It recommends that the requested partial payment be made.

settlement proposal against

NAME OF CONTRACTOR