Public Services and Procurement Canada
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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:
I certify that:
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.
Certificate of Contractor2 Contractor 's Signature: _____________________________________
Certificate of Contractor2 Title:
Certificate of Contractor2 Date (YYYY-MM-DD):
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