If necessary, use form PWGSC-TPSGC 1112 to record detail costs

Contractor's Name and Address:

Claim No.:

Date (YYYY-MM-DD):

Contract Price:

File No.:

Contract Serial No.:

Contractor's Procurement Business Number (PBN):

Financial Code(s):

Contractor's Report of Work Progress (if needed, use additional sheets):

Contractor's GST/HST No.:

Contractor’s QST No.:

Period of Work Covered by the Claim:

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Certificate of Contractor

I certify that:

• All authorizations required under the contract have been obtained. The claim is consistent with the progress of the work and is in accordance with the contract.
• Indirect costs have been paid for or accrued in the accounts.
• Direct materials and work under subcontract have been received, accepted and either paid for or accrued in my/our accounts following receipt of invoice from vendor/subcontractor, and have been or will be used exclusively for the purpose of the contract.
• All direct labour costs have been paid for or accrued in the accounts and all such costs were incurred exclusively for the purpose of the contract.
• All other direct costs have been paid for or accrued in the accounts following receipt of applicable invoice or expense voucher and all such costs were incurred exclusively for the purpose of the contract; and
• No liens, encumbrances, charges or other claims exist against the work except those which may arise by operation of law such as a lien in the nature of an unpaid contractor's lien and in respect of which a progress payment and/or advance payment has been or will be made by Canada.

Certificate of Contractor Contractor 's Signature: _____________________________________

Certificate of Contractor Title:

Certificate of Contractor Date (YYYY-MM-DD):

This claim, or a portion of this claim, is for an advance payment.

I certify that:

• The funds received will be used solely for the purpose of the contract and attached is a complete description of the purpose to which the advance payment will be applied.
• The amount of the payment is established in accordance with the conditions of the contract.
• The contractor is not in default of its obligations under the contract.
• The payment is related to an identifiable part of the contractual work.

Certificate of Contractor2 Contractor 's Signature: _____________________________________

Certificate of Contractor2 Title:

Certificate of Contractor2 Date (YYYY-MM-DD):

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Certificates of Departmental Representatives

Scientific/Project/Inspection Authority: I certify that the work meets the quality standards required under the contract, and its progress is in accordance with the conditions of the contract.

Inspection Authority (all other contracts): I certify that the quality of the work performed is in accordance with the standards required under the contract.

Signature of Scientific / Project / Inspection Authority: _____________________________________

Signature of Scientific / Project / Inspection Authority Date (YYYY-MM-DD):

PWGSC Contracting Authority: I certify that, to the best of my knowledge, the claim is consistent with the progress of the work and is in accordance with the contract. This claim, however, may be subject to further verification and any necessary adjustment before final settlement.

Contracting Authority Signature: _____________________________________

Contracting Authority Title:

Contracting Authority Date (YYYY-MM-DD):

Client's Authorized Signing Officer - (Must sign the interim claim): I certify that the claim is in accordance with the contract.

Client Signature: _____________________________________

Client Title:

Client Date (YYYY-MM-DD):

Client's Authorized Signing Officer - (Must sign the final claim): I certify that all goods have been received and all services have been rendered, that the work has been properly performed and that the claim is in accordance with the contract.

Client 2 Signature: _____________________________________

Client 2 Title:

Client 2 Date (YYYY-MM-DD):

Clear Data