ta-w10 payments page 1 of 4 (consultantta-w1059 (07/2019) payments (consultant) page 2 of 4 i. % of...
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![Page 1: TA-W10 PAYMENTS Page 1 of 4 (CONSULTANTTA-W1059 (07/2019) PAYMENTS (CONSULTANT) Page 2 of 4 I. % of Work Completed To Date (Based on Dollars) A. List all Subconsultants, Suppliers](https://reader033.vdocuments.us/reader033/viewer/2022060718/607e398147461829ba26573a/html5/thumbnails/1.jpg)
I. % ofWork
Completed To Date
(Based on Dollars)
A. List all CertifiedSubconsultants and
Suppliers
D. AgreementAmount
C. EstimatedStart/End
Date
E. Supplier at 60%(AutomaticallyCalculated)/
Broker's Fee Credit
B. Certification/Designations
G. PreviousPayments
F. Payments thisMonth
H. Total Paymentsto Date
TA-W1059 (07/2019) PAYMENTS (CONSULTANT)
Email completed form to the Office of Compliance at [email protected] or mail to P.O. Box 189, Albany, NY 12201-0189
Consultant Name and Address Contract Goals
$
Preparer's Name (Print)
Grand Total
INSTRUCTIONS: This form must be submitted by the consultant to report actual monthly payments made to certify DBEs/MWBEs/SDVOBs. Complete and accurate forms must be submitted by the 10th of the month reflecting payments made during the previous month. Please Note: Broker Fees and Supplier Credits (60%) will be automatically calculated.
PREPARED BY:
Page 1 of 4
MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
D. No.
MBE % - $ SDVOB % - $
WBE % - $ DBE % - $
$
$
Supplier @ 60%
$MBE
WBE
DBE
SDVOB
$
$
Supplier @ 60%
$MBE
WBE
DBE
SDVOB
$
$
Supplier @ 60%
$MBE
WBE
DBE
SDVOB
$
$
Broker (Fee Only)
Broker (Fee Only)
Broker (Fee Only)
Broker (Fee Only)
Preparer's Signature
Email Address
$
%
%
%
%
$
$
$
$
$
$
$
$
$
$
$
WBE Sub Total $
Date Submitted
$DBE Sub Total
No Payments
$SDVOB Sub Total
$MBE Sub Total
$
$
$
$
$
$
$
$
$
$
$
$
%
%
%
%
-)(Phone No.
End Date
Start Date
End Date
Start Date
End Date
Start Date
End Date
Start Date
60% Payment 60% Payment 60% Payment
60% Payment 60% Payment 60% Payment
60% Payment60% Payment 60% Payment
60% Payment 60% Payment 60% Payment
Contract Value $ Contract Number
ReportingMonth / Year
![Page 2: TA-W10 PAYMENTS Page 1 of 4 (CONSULTANTTA-W1059 (07/2019) PAYMENTS (CONSULTANT) Page 2 of 4 I. % of Work Completed To Date (Based on Dollars) A. List all Subconsultants, Suppliers](https://reader033.vdocuments.us/reader033/viewer/2022060718/607e398147461829ba26573a/html5/thumbnails/2.jpg)
TA-W1059 (07/2019) PAYMENTS (CONSULTANT)
Page 2 of 4
I. % ofWork
Completed To Date
(Based on Dollars)
A. List all Subconsultants,Suppliers and Trucking Firms
D. AgreementAmount
C. EstimatedStart/End
Date
E. Supplier at 60%(AutomaticallyCalculated)/
Broker's Fee Credit
B. Certification/ Designations
G. PreviousPayments
F. Payments thisMonth
H. Total Paymentsto Date
$MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
$
Broker (Fee Only)
$
%
$ $
No Payments
$ $ $End Date
Start Date60% Payment 60% Payment 60% Payment
$MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
$
Broker (Fee Only)
$
%
$ $
$ $ $End Date
Start Date60% Payment 60% Payment 60% Payment
$MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
$
Broker (Fee Only)
$
%
$ $
$ $ $End Date
Start Date60% Payment 60% Payment 60% Payment
$MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
$
Broker (Fee Only)
$
%
$ $
$ $ $End Date
Start Date60% Payment 60% Payment 60% Payment
$MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
$
Broker (Fee Only)
$
%
$ $
$ $ $End Date
Start Date60% Payment 60% Payment 60% Payment
$MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
$
Broker (Fee Only)
$
%
$ $
$ $ $End Date
Start Date60% Payment 60% Payment 60% Payment
$MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
$
Broker (Fee Only)
$
%
$ $
$ $ $End Date
Start Date60% Payment 60% Payment 60% Payment
D No.
![Page 3: TA-W10 PAYMENTS Page 1 of 4 (CONSULTANTTA-W1059 (07/2019) PAYMENTS (CONSULTANT) Page 2 of 4 I. % of Work Completed To Date (Based on Dollars) A. List all Subconsultants, Suppliers](https://reader033.vdocuments.us/reader033/viewer/2022060718/607e398147461829ba26573a/html5/thumbnails/3.jpg)
TA-W1059 (07/2019) PAYMENTS (CONSULTANT)
Page 3 of 4
I. % ofWork
Completed To Date
(Based on Dollars)
A. List all Subconsultants,Suppliers and Trucking Firms
D. AgreementAmount
C. EstimatedStart/End
Date
E. Supplier at 60%(AutomaticallyCalculated)/
Broker's Fee Credit
B. Certification/ Designations
G. PreviousPayments
F. Payments thisMonth
H. Total Paymentsto Date
$MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
$
Broker (Fee Only)
$
%
$ $
No Payments
$ $ $End Date
Start Date60% Payment 60% Payment 60% Payment
$MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
$
Broker (Fee Only)
$
%
$ $
$ $ $End Date
Start Date60% Payment 60% Payment 60% Payment
$MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
$
Broker (Fee Only)
$
%
$ $
$ $ $End Date
Start Date60% Payment 60% Payment 60% Payment
$MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
$
Broker (Fee Only)
$
%
$ $
$ $ $End Date
Start Date60% Payment 60% Payment 60% Payment
$MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
$
Broker (Fee Only)
$
%
$ $
$ $ $End Date
Start Date60% Payment 60% Payment 60% Payment
$MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
$
Broker (Fee Only)
$
%
$ $
$ $ $End Date
Start Date60% Payment 60% Payment 60% Payment
$MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
$
Broker (Fee Only)
$
%
$ $
$ $ $End Date
Start Date60% Payment 60% Payment 60% Payment
D No.
![Page 4: TA-W10 PAYMENTS Page 1 of 4 (CONSULTANTTA-W1059 (07/2019) PAYMENTS (CONSULTANT) Page 2 of 4 I. % of Work Completed To Date (Based on Dollars) A. List all Subconsultants, Suppliers](https://reader033.vdocuments.us/reader033/viewer/2022060718/607e398147461829ba26573a/html5/thumbnails/4.jpg)
TA-W1059 (07/2019) PAYMENTS (CONSULTANT)
Page 4 of 4
I. % ofWork
Completed To Date
(Based on Dollars)
A. List all Subconsultants,Suppliers and Trucking Firms
D. AgreementAmount
C. EstimatedStart/End
Date
E. Supplier at 60%(AutomaticallyCalculated)/
Broker's Fee Credit
B. Certification/Designations
G. PreviousPayments
F. Payments thisMonth
H. Total Paymentsto Date
$MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
$
Broker (Fee Only)
$
%
$ $
No Payments
$ $ $End Date
Start Date60% Payment 60% Payment 60% Payment
$MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
$
Broker (Fee Only)
$
%
$ $
$ $ $End Date
Start Date60% Payment 60% Payment 60% Payment
$MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
$
Broker (Fee Only)
$
%
$ $
$ $ $End Date
Start Date60% Payment 60% Payment 60% Payment
$MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
$
Broker (Fee Only)
$
%
$ $
$ $ $End Date
Start Date60% Payment 60% Payment 60% Payment
$MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
$
Broker (Fee Only)
$
%
$ $
$ $ $End Date
Start Date60% Payment 60% Payment 60% Payment
$MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
$
Broker (Fee Only)
$
%
$ $
$ $ $End Date
Start Date60% Payment 60% Payment 60% Payment
$MBE
WBE
DBE
SDVOB
Supplier @ 60%
$
$
Broker (Fee Only)
$
%
$ $
$ $ $End Date
Start Date60% Payment 60% Payment 60% Payment
D No.