The National Head Start Facilities Desk

Use this sample periodic payment form when you elect to have the contractor document payments to those involved in the renovation or construction project. For grantees or delegate agencies, the information listed documents that the contractor has paid all costs associated with the project. This keeps the contractor from placing a lien on the Head Start or Early Head Start grantee or delegate property.

-SAMPLE-

GRANTEE ______________________________________ DATE _________________

CONTRACTOR _________________________________________________________

PERIODIC PAYMENT REQUEST NUMBER _________________________________

AMOUNT OF PERIODIC PAYMENT________________________________________

The contractor certifies that all labor and materials covered under this payment request have been paid in full. The contractor certifies that all work in this pay request has been completed. The contractor, upon payment waives all interest and rights including liens to this contract and certifies that all payments processed to the contractor including change orders total the amount due for work performed under this pay request.

___________________________________________________ 
CONTRACTOR'S REPRESENTATIVE

___________________________________________________ 
CONTRACTING OFFICER OR REPRESENTATIVE

___________________________________________________ 
PROJECT MANAGER

Last Updated: September 12, 2024