INVOICE FOR PAYMENT OF AGREED STIPEND DESIGNBUILD FIRM (FIRM)

2122 TREASURERS’ ASSOCIATION OF VA COUNTYCITYTOWN MEMBERSHIP APPLICATION INVOICE
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REQUEST FOR PAYMENT OF AGREED STIPEND

INVOICE FOR PAYMENT OF AGREED STIPEND




Design-Build Firm (Firm): __________________________________________


Design-Build Project: __________________________________________


Stipend Amount: $________________



In accordance with the Request for Proposals (RFP) issued by the Montana Department of Transportation (MDT) for this Design-Build (DB) project, the Firm shown above hereby requests that MDT pay the Firm the stipulated stipend for having submitted its Proposal for the project. As stated in the RFP, the Firm understands that the stipend may not reimburse it for all of the Firm’s expenses in preparing the Proposal, but the stipend is an agreed-upon amount in order to obtain Proposals from the short-listed Firms.


In submitting this request for payment of the stipend, the Firm certifies under oath that:


It was one of the Firms short-listed by MDT for the project;


It submitted a Proposal for the project;


The Proposal was a good-faith, responsive submission, as requested by the RFP; and,


MDT has determined that the Proposal is responsive.




________________________________________ __________________________________

Signature of Authorized Representative Printed Name



Signed and Sworn to before me on the______ day of _______________, 20__.



___________________________________ _____________________________________

Printed Name Notary Public for the State of Montana

Residing at _______________________

My Commission Expires: ____________


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