PROGRESS PAYMENT CERTIFICATE Attachment 4a A separate certificate must be used for each claim on each project (A Progress Payment Certificate is not required for the final claim) Claim No. 1 (1st 40%) Road Project Grant OR Commodity Route Supplementary Grant Claim No. 2 (2) (2nd 40%) Black Spot Program (State and National (1)) Regional Run-off Road Crashes Programme (Please mark appropriate box) (Please mark appropriate box) Project Details Local Government: Financial Year: Road Name: Proposal / Job No.: Work Description: to Section (SLK’s): MANDATORY INFORMATION ALL PROJECTS Approved Project Allocations (Project Milestones) Total Project Allocation State Contribution (2/3) LG Contribution (1/3) Project’s estimated or actual commencement date? / / …..… ..…… …….. $ $ $ completion date? Project’s estimated or actual / / …..… ..…… …….. Claim Details for State Contribution If a detailed design is required, estimated completion date? / / …..… ..…… …….. Previous Claim/s Current Claim Total Funds Claimed Are land access agreements to be concluded, estimated date? / / …..… ..…… …….. $ $ $ If project clearances are required, estimated completion date? / / …..… ..…… …….. If service relocations are required, estimated completion date? / / …..… ..…… …….. Estimated date of second 40% claim? / / …..… ..…… …….. Notes: (1) No LG contribution required for National Black Spot projects. (2) Prior to claiming Claim No. 2, Actual Expenditure to date must exceed 40% of ……………………….………………….. ………………………………….... the State Contribution (Signature) (Name) Chief Executive Officer / / Date: ….… ….…. …….
PROGRESS PAYMENT CERTIFICATE Attachment 4a A separate certificate must be used for each claim on each project (A Progress Payment Certificate is not required for the final claim) Road Project Grant OR Commodity Route Supplementary Grant Claim No. 1 (1st 40%) Black Spot Program (State and National (1)) Claim No. 2 (2) (2nd 40%) Regional Run-off Road Crashes Programme (Please mark appropriate box) (Please mark appropriate box) Project Details Local Government: Financial Year: Road Name: Proposal / Job No.: Work Description: Section (SLK’s): to Approved Project Allocations MANDATORY INFORMATION ALL PROJECTS (Project Milestones) Total Project Allocation State Contribution (2/3) LG Contribution (1/3) Project’s estimated or actual commencement date? …..… / ..…… / …….. $ $ $ Project’s estimated or actual completion date? …..… / ..…… / …….. Claim Details for State Contribution If a detailed design is required, estimated completion date? …..… / ..…… / …….. Previous Claim/s Current Claim Total Funds Claimed Are land access agreements to be concluded, estimated date? …..… / ..…… / …….. $ $ $ If project clearances are required, estimated completion date? …..… / ..…… / …….. If service relocations are required, estimated completion date? …..… / ..…… / …….. Estimated date of second 40% claim? …..… / ..…… / …….. Notes: ……………………….………………….. ………………………………….... (1) No LG contribution required for National Black Spot projects. (2) Prior to claiming Claim No. 2, Actual Expenditure to date must exceed 40% of the State Contribution (Signature) (Name) Chief Executive Officer Date: ….… / ….…. / …….