Completing the State Aid Payment Request

(SAPR)

Tips

• Each spring check on the State Aid Finance web page for the current version of the State Aid Pay Request form.http://www.dot.state.mn.us/safinance/formsandresolutions.html

• Save your Payment Requests on a project so each additional request can build on the previous information for consistency.

• Include all funding on each pay request even if you are not requesting payment on this request.

Local Agency Information

The top section provides information about the local agency and provides project identification.

County / City: Name of local agency requesting funds. An agency cannot request payment of another agency’s funds.Report: Refers to partial or final payment request. There may be several partial payments through the project but should only be one final.Project Type: SAP projects are projects that do not have federal funds; SP projects have federal funds.Project Number: Use the 9 digit format.Bid Opening: Use the date your agency opens the bids.Award Date: Use the date your agency grants the contract to the contractor. Some agencies refer to this as the “Letting Date”. The Bid Opening and Award Date can be the same date. Tied Projects: If more than one project is covered under one contract they are “tied”. Referencing them here helps our office if there are funding questions.Local Project Number: Optional, used if your agency has a numbering system different from the State Aid system.Bond Company: This is the contractor’s bond agency named by the contractor in the contract paperwork.Contractor: Name of the contractor on the awarded bidConstruction Completion Date: Used only on the final payment request, and should reflect the date that the work was certified 100% complete.

MN/DOT 30172 revised June 2013

County/City Report: Partial SP SAP Project #:

Bid Opening Date: Award Date:

Local Proj. ID (opt) Contractor:

Constr. Completed Date:

Project Funding:

Contract Costs (this SAP only) %Requested

FUND

Municipal (MSAS > 5000)

Regular (CSAH)

Municipal (MSAH < 5000)

Town Bridge

Special Town Bridge

Turnback

State Park

State Aid Disaster

Local / Other

Local / Other

Federal

State Aid Bonds Applied

Credit for Local Effort (attach abstract detailing items)

BrBnd/Oth Bnd Prgms

(identify eligible items)

Sub-Total

Other Costs %FUND *Description Requested

TOTAL

Remarks:

Approved by: County/City Engineer Date Approved by: State Aid Finance Date

I certify that: (a) Engineering & ROW costs requested above are a reimbursement for costs incurred, or a percentage of estimated costs. (b) Wage rates specified in the contract were paid and are equal or exceed the minimum hourly rates required for work on state funded projects as determined by the MN Dept. of Labor and Industry. (c) Inspection on the state-aid funded portions of this project were performed by personnel certified in accordance with state-aid directives. (d) Work required by this contract was completed in accordance with and pursuant to the terms of this contract. (e) Payment and performance bonds for the full amount of the contract have been provided with aggregate liability of the bond(s) to twice the full amount of the contract.

I certify all costs are reasonable. For finals I accept all work performance as in compliance with the approved plans and specifications. DSAE signature for Maintenance Facilities is not required on this form; prior approval was received.

/ /Approved by: District State Aid Engineer Date

/ / / /

-$ -$ -$ -$

*Other Cost Description: Right-of-Way (ROW), Engineering (ENG)-Max 25%, Maintenance Facility (MF), Force Account (FA). FA includes work performed by force labor such as work by local agencies, R/R, utility work, or contractors if not let under bids. Also agency furnished materials must include a FA agreement.

-$ -$

-$ -$

Total Oblig/Paid Requested Payments Pay at this time

-$ -$

-$ -$ -$ -$

Amount Less Previous

-$ Acct# Total Grant Amount Certif ied & Paid To Date

specify

specify

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

Total Obligated Amount Less PreviousCosts Requested Payments Pay at this time

Funding below is for this project number only. Costs for projects or agreements tied to this project should not be included on this request. A separate State Aid Payment Request must be submitted for each project number. Final reports must includea final estimate detailing quantity, unit price and extension splits for each project number. Bridge eligible items must be identified on the abstract.

Tied Projects:

Bond Co.

STATE AID PAYMENT REQUEST

Final Project Type:

Check if Bond Eligible Items are 100% Complete.

Obligated Costs Column

This column includes funding requests for the project named in the header. Projects are never combined on a pay request even if they are under the same contract. All other costs will be listed in the “Other Costs” area .

Municipal (MSAS) is used by the Cities only.Regular (CSAH), Municipal (CSAH), Regular Town Bridge and Special Town Bridge are used by counties only.All the other funding sources can be used by either entity.Letting: The “Sub-Total” at the bottom of this column MUST equal the total of the awarded bid. It is helpful to save this form and build each pay request from the last so all the funding is consistently included through the project.

Final: On the final payment request the “Sub-Total” MUST now be equal to the final work certified on the project.

MN/DOT 30172 revised June 2013

County/City Report: Partial SP SAP Project #:

Bid Opening Date: Award Date:

Local Proj. ID (opt) Contractor:

Constr. Completed Date:

Project Funding:

Contract Costs (this SAP only) %Requested

FUND

Municipal (MSAS > 5000)

Regular (CSAH)

Municipal (MSAH < 5000)

Town Bridge

Special Town Bridge

Turnback

State Park

State Aid Disaster

Local / Other

Local / Other

Federal

State Aid Bonds Applied

Credit for Local Effort (attach abstract detailing items)

BrBnd/Oth Bnd Prgms

(identify eligible items)

Sub-Total

Other Costs %FUND *Description Requested

TOTAL

Remarks:

Approved by: County/City Engineer Date Approved by: State Aid Finance Date

I certify that: (a) Engineering & ROW costs requested above are a reimbursement for costs incurred, or a percentage of estimated costs. (b) Wage rates specified in the contract were paid and are equal or exceed the minimum hourly rates required for work on state funded projects as determined by the MN Dept. of Labor and Industry. (c) Inspection on the state-aid funded portions of this project were performed by personnel certified in accordance with state-aid directives. (d) Work required by this contract was completed in accordance with and pursuant to the terms of this contract. (e) Payment and performance bonds for the full amount of the contract have been provided with aggregate liability of the bond(s) to twice the full amount of the contract.

I certify all costs are reasonable. For finals I accept all work performance as in compliance with the approved plans and specifications. DSAE signature for Maintenance Facilities is not required on this form; prior approval was received.

/ /Approved by: District State Aid Engineer Date

/ / / /

-$ -$ -$ -$

*Other Cost Description: Right-of-Way (ROW), Engineering (ENG)-Max 25%, Maintenance Facility (MF), Force Account (FA). FA includes work performed by force labor such as work by local agencies, R/R, utility work, or contractors if not let under bids. Also agency furnished materials must include a FA agreement.

-$ -$

-$ -$

Total Oblig/Paid Requested Payments Pay at this time

-$ -$

-$ -$ -$ -$

Amount Less Previous

-$ Acct# Total Grant Amount Certif ied & Paid To Date

specify

specify

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

Total Obligated Amount Less PreviousCosts Requested Payments Pay at this time

Funding below is for this project number only. Costs for projects or agreements tied to this project should not be included on this request. A separate State Aid Payment Request must be submitted for each project number. Final reports must includea final estimate detailing quantity, unit price and extension splits for each project number. Bridge eligible items must be identified on the abstract.

Tied Projects:

Bond Co.

STATE AID PAYMENT REQUEST

Final Project Type:

Check if Bond Eligible Items are 100% Complete.

Funding Sources

Allotments: The first 4 funding types are annual allotments. Up to 95% of the total eligible costs can be requested at letting.Grants: The next 3 funding types are grants awarded based on availability and are requested by project. Up to 95% of the total eligible costs can be requested at letting.State Aid Disaster: Available to counties and cities on a case by case basis when qualifying damage has occurred to their road system. The funds are disbursed and the SAPR is usually reporting how much of the money has been spent. Unspent funds are returned to State Aid.Reported Funding: These are the funds that are “unreimbursed” project funding. We require that you report 100% of the project funding, even if it is not State Aid reimbursed. Local funding has 2 lines for your convenience, we do not separate these for our purposes.Bridge & Other Bond Funds: Bond funds will not be paid out until eligible costs have been certified. Payment requests can be submitted periodically as work is completed. It is important to use the bond account number found on your grant letter. The “Total Grant Amount” is based on your awarded bid, not on the grant letter. A breakdown showing eligible bridge items must be submitted with the initial pay request and the total grant cannot be greater than that amount. When bond eligible work is 100% complete (not paid) check the box. This allows us to maximize the funding. NOTE: Only 95% of bond items are paid out until the project is “finaled”. We will hold the remaining 5% for your project.

MN/DOT 30172 revised June 2013

County/City Report: Partial SP SAP Project #:

Bid Opening Date: Award Date:

Local Proj. ID (opt) Contractor:

Constr. Completed Date:

Project Funding:

Contract Costs (this SAP only) %Requested

FUND

Municipal (MSAS > 5000)

Regular (CSAH)

Municipal (MSAH < 5000)

Town Bridge

Special Town Bridge

Turnback

State Park

State Aid Disaster

Local / Other

Local / Other

Federal

State Aid Bonds Applied

Credit for Local Effort (attach abstract detailing items)

BrBnd/Oth Bnd Prgms

(identify eligible items)

Sub-Total

Other Costs %FUND *Description Requested

TOTAL

Remarks:

Approved by: County/City Engineer Date Approved by: State Aid Finance Date

I certify that: (a) Engineering & ROW costs requested above are a reimbursement for costs incurred, or a percentage of estimated costs. (b) Wage rates specified in the contract were paid and are equal or exceed the minimum hourly rates required for work on state funded projects as determined by the MN Dept. of Labor and Industry. (c) Inspection on the state-aid funded portions of this project were performed by personnel certified in accordance with state-aid directives. (d) Work required by this contract was completed in accordance with and pursuant to the terms of this contract. (e) Payment and performance bonds for the full amount of the contract have been provided with aggregate liability of the bond(s) to twice the full amount of the contract.

I certify all costs are reasonable. For finals I accept all work performance as in compliance with the approved plans and specifications. DSAE signature for Maintenance Facilit ies is not required on this form; prior approval was received.

/ /Approved by: District State Aid Engineer Date

/ / / /

-$ -$ -$ -$

*Other Cost Description: Right-of-Way (ROW), Engineering (ENG)-Max 25%, Maintenance Facility (MF), Force Account (FA). FA includes work performed by force labor such as work by local agencies, R/R, utility work, or contractors if not let under bids. Also agency furnished materials must include a FA agreement.

-$ -$

-$ -$

Total Oblig/Paid Requested Payments Pay at this time

-$ -$

-$ -$ -$ -$

Amount Less Previous

-$ Acct# Total Grant Amount Certif ied & Paid To Date

specify

specify

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

Total Obligated Amount Less PreviousCosts Requested Payments Pay at this time

Funding below is for this project number only. Costs for projects or agreements tied to this project should not be included on this request. A separate State Aid Payment Request must be submitted for each project number. Final reports must includea final estimate detailing quantity, unit price and extension splits for each project number. Bridge eligible items must be identified on the abstract.

Tied Projects:

Bond Co.

STATE AID PAYMENT REQUEST

Final Project Type:

Check if Bond Eligible Items are 100% Complete.

Funding Requested

The yellow shaded fields must be entered and the other fields will auto calculate.

Allotted Funds: As long as there is a balance in the allotment account these funds will be paid at the percentage requested up to 95% and the remaining 5% will be encumbered. “Short Payments” occur when the allotment balance is insufficient. Available funds will be released up to the requested amount but nothing will be encumbered in an advance situation. The unpaid portion will be released when the new allotment comes in or a resolution to advance is received.Granted Funds: After the letting up to 95% of the eligible costs can be requested and paid. Any remaining funds up to the original grant amount will remain allocated to the project until it is finaled. • Special Town Bridge granted on a project will be

used after the Regular Town Bridge is depleted and the funds should be applied for that way.

• Turnback and State Park funds are generally available for project expenses up to the grant approved amount. They are not usually tied to specific spec items like bridge funds are.

MN/DOT 30172 revised June 2013

County/City Report: Partial SP SAP Project #:

Bid Opening Date: Award Date:

Local Proj. ID (opt) Contractor:

Constr. Completed Date:

Project Funding:

Contract Costs (this SAP only) %Requested

FUND

Municipal (MSAS > 5000)

Regular (CSAH)

Municipal (MSAH < 5000)

Town Bridge

Special Town Bridge

Turnback

State Park

State Aid Disaster

Local / Other

Local / Other

Federal

State Aid Bonds Applied

Credit for Local Effort (attach abstract detailing items)

BrBnd/Oth Bnd Prgms

(identify eligible items)

Sub-Total

Other Costs %FUND *Description Requested

TOTAL

Remarks:

Approved by: County/City Engineer Date Approved by: State Aid Finance Date

I certify that: (a) Engineering & ROW costs requested above are a reimbursement for costs incurred, or a percentage of estimated costs. (b) Wage rates specified in the contract were paid and are equal or exceed the minimum hourly rates required for work on state funded projects as determined by the MN Dept. of Labor and Industry. (c) Inspection on the state-aid funded portions of this project were performed by personnel certified in accordance with state-aid directives. (d) Work required by this contract was completed in accordance with and pursuant to the terms of this contract. (e) Payment and performance bonds for the full amount of the contract have been provided with aggregate liability of the bond(s) to twice the full amount of the contract.

I certify all costs are reasonable. For finals I accept all work performance as in compliance with the approved plans and specifications. DSAE signature for Maintenance Facilities is not required on this form; prior approval was received.

/ /Approved by: District State Aid Engineer Date

/ / / /

-$ -$ -$ -$

*Other Cost Description: Right-of-Way (ROW), Engineering (ENG)-Max 25%, Maintenance Facility (MF), Force Account (FA). FA includes work performed by force labor such as work by local agencies, R/R, utility work, or contractors if not let under bids. Also agency furnished materials must include a FA agreement.

-$ -$

-$ -$

Total Oblig/Paid Requested Payments Pay at this time

-$ -$

-$ -$ -$ -$

Amount Less Previous

-$ Acct# Total Grant Amount Certif ied & Paid To Date

specify

specify

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

Total Obligated Amount Less PreviousCosts Requested Payments Pay at this time

Funding below is for this project number only. Costs for projects or agreements tied to this project should not be included on this request. A separate State Aid Payment Request must be submitted for each project number. Final reports must includea final estimate detailing quantity, unit price and extension splits for each project number. Bridge eligible items must be identified on the abstract.

Tied Projects:

Bond Co.

STATE AID PAYMENT REQUEST

Final Project Type:

Check if Bond Eligible Items are 100% Complete.

Reported Funding

These funds will not calculate into a payment amount because they are not reimbursable from State Aid.

Local / Other: These can be from another state entity, local community, or tribal government. They do not have to be broken out for our purposes.Federal funds are reimbursed by State Aid, but they must be requested through the Delegated Contract Process (DCP) on the State Aid Finance webpage. This process is completed as eligible costs are incurred.State Aid Bonds (Local Agency Bonds) provides a place to report “applying” bond funds already received to an eligible project. This must be done if a local agency issues a bond and uses their State Aid Allotments for the repayment.Credit For Local Effort will probably be removed from this form as the new “Needs” program is developed. At this time it is not being considered to be a part of future needs and our form will change when we know for certain.

MN/DOT 30172 revised June 2013

County/City Report: Partial SP SAP Project #:

Bid Opening Date: Award Date:

Local Proj. ID (opt) Contractor:

Constr. Completed Date:

Project Funding:

Contract Costs (this SAP only) %Requested

FUND

Municipal (MSAS > 5000)

Regular (CSAH)

Municipal (MSAH < 5000)

Town Bridge

Special Town Bridge

Turnback

State Park

State Aid Disaster

Local / Other

Local / Other

Federal

State Aid Bonds Applied

Credit for Local Effort (attach abstract detailing items)

BrBnd/Oth Bnd Prgms

(identify eligible items)

Sub-Total

Other Costs %FUND *Description Requested

TOTAL

Remarks:

Approved by: County/City Engineer Date Approved by: State Aid Finance Date

I cert ify that: (a) Engineering & ROW costs requested above are a reimbursement for costs incurred, or a percentage of estimated costs. (b) Wage rates specified in the contract were paid and are equal or exceed the minimum hourly rates required for work on state funded projects as determined by the MN Dept. of Labor and Industry. (c) Inspection on the state-aid funded portions of this project were performed by personnel certified in accordance with state-aid directives. (d) Work required by this contract was completed in accordance with and pursuant to the terms of this contract . (e) Payment and performance bonds for the full amount of the contract have been provided with aggregate liability of the bond(s) to twice the full amount of the contract.

I cert ify all costs are reasonable. For finals I accept all work performance as in compliance with the approved plans and specifications. DSAE signature for Maintenance Facilit ies is not required on this form; prior approval was received.

/ /Approved by: District State Aid Engineer Date

/ / / /

-$ -$ -$ -$

*Other Cost Description: Right-of-Way (ROW), Engineering (ENG)-Max 25%, Maintenance Facility (MF), Force Account (FA). FA includes work performed by force labor such as work by local agencies, R/R, utility work, or contractors if not let under bids. Also agency furnished materials must include a FA agreement.

-$ -$

-$ -$

Total Oblig/Paid Requested Payments Pay at this time

-$ -$

-$ -$ -$ -$

Amount Less Previous

-$ Acct# Total Grant Amount Certif ied & Paid To Date

specify

specify

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

Total Obligated Amount Less PreviousCosts Requested Payments Pay at this time

Funding below is for this project number only. Costs for projects or agreements tied to this project should not be included on this request. A separate State Aid Payment Request must be submitted for each project number. Final reports must includea final estimate detailing quantity, unit price and extension splits for each project number. Bridge eligible items must be identified on the abstract.

Tied Projects:

Bond Co.

STATE AID PAYMENT REQUEST

Final Project Type:

Check if Bond Eligible Items are 100% Complete.

Bridge Funds

All pay requests for Bridge Funds must include a breakdown of eligible bridge costs and ineligible bridge costs in the same format as the Engineer’s Estimate.Town Bridge (County Only) Regular funds are always used first to pay the eligible bridge items on a township bridge project. Once these are depleted and the local share has been applied other Special Town Bridge, bond, or local funds can be used. Bridge & Other Bond funds do not allow you to request a percentage to pay because you request after the work is certified. The amount the local agency has certified and paid is 100% eligible to be reimbursed up to the authorized grant amount. You will only be paid 95% of these costs until the project is finaled.The “Total Grant Amount” is based on the awarded bid’s eligible bridge costs not on the original grant amount.The Account number of the bond funds is provided to you on your award letter and should be referenced on the pay request. It insures that the bond funds are paid from the correct account when the pay request is processed.When the bond eligible items are 100% complete check the box on the payment request. This allows the unused funds to be reallocated.

MN/DOT 30172 revised June 2013

County/City Report: Partial SP SAP Project #:

Bid Opening Date: Award Date:

Local Proj. ID (opt) Contractor:

Constr. Completed Date:

Project Funding:

Contract Costs (this SAP only) %Requested

FUND

Municipal (MSAS > 5000)

Regular (CSAH)

Municipal (MSAH < 5000)

Town Bridge

Special Town Bridge

Turnback

State Park

State Aid Disaster

Local / Other

Local / Other

Federal

State Aid Bonds Applied

Credit for Local Effort (attach abstract detailing items)

BrBnd/Oth Bnd Prgms

(identify eligible items)

Sub-Total

Other Costs %FUND *Description Requested

TOTAL

Remarks:

Approved by: County/City Engineer Date Approved by: State Aid Finance Date

I certify that: (a) Engineering & ROW costs requested above are a reimbursement for costs incurred, or a percentage of estimated costs. (b) Wage rates specified in the contract were paid and are equal or exceed the minimum hourly rates required for work on state funded projects as determined by the MN Dept. of Labor and Industry. (c) Inspection on the state-aid funded portions of this project were performed by personnel certified in accordance with state-aid directives. (d) Work required by this contract was completed in accordance with and pursuant to the terms of this contract. (e) Payment and performance bonds for the full amount of the contract have been provided with aggregate liability of the bond(s) to twice the full amount of the contract.

I certify all costs are reasonable. For finals I accept all work performance as in compliance with the approved plans and specifications. DSAE signature for Maintenance Facilities is not required on this form; prior approval was received.

/ /Approved by: District State Aid Engineer Date

/ / / /

-$ -$ -$ -$

*Other Cost Description: Right-of-Way (ROW), Engineering (ENG)-Max 25%, Maintenance Facility (MF), Force Account (FA). FA includes work performed by force labor such as work by local agencies, R/R, utility work, or contractors if not let under bids. Also agency furnished materials must include a FA agreement.

-$ -$

-$ -$

Total Oblig/Paid Requested Payments Pay at this time

-$ -$

-$ -$ -$ -$

Amount Less Previous

-$ Acct# Total Grant Amount Certif ied & Paid To Date

specify

specify

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

Total Obligated Amount Less PreviousCosts Requested Payments Pay at this time

Funding below is for this project number only. Costs for projects or agreements tied to this project should not be included on this request. A separate State Aid Payment Request must be submitted for each project number. Final reports must includea final estimate detailing quantity, unit price and extension splits for each project number. Bridge eligible items must be identified on the abstract.

Tied Projects:

Bond Co.

STATE AID PAYMENT REQUEST

Final Project Type:

Check if Bond Eligible Items are 100% Complete.

Other Costs

Report project expenses that are not part of the contract costs here. Indicate the funding source the costs will be paid from.Incurred costs will be paid at 100% and estimated costs will be paid at 95%.The only descriptions used at State Aid are ROW, ENG, FA, and MF please use these codes on your pay requests.

Right of Way (ROW): Submit clear documentation of the payments or costs to acquire ROW. A listing of these can be found on the SALT website.Engineering (ENG): Submit documentation of force labor costs or an invoice from a consultant. Combine preliminary and construction engineering into one line unless there are multiple funding sources. Force Account (FA): Submit documentation of force labor costs or an invoice from an external source like utilities or railroad. These costs also require a Force Account Agreement to be completed and submitted with the pay request.Maintenance Facilities (MF): (County Only) Submit progress billings from the contract.

MN/DOT 30172 revised June 2013

County/City Report: Partial SP SAP Project #:

Bid Opening Date: Award Date:

Local Proj. ID (opt) Contractor:

Constr. Completed Date:

Project Funding:

Contract Costs (this SAP only) %Requested

FUND

Municipal (MSAS > 5000)

Regular (CSAH)

Municipal (MSAH < 5000)

Town Bridge

Special Town Bridge

Turnback

State Park

State Aid Disaster

Local / Other

Local / Other

Federal

State Aid Bonds Applied

Credit for Local Effort (attach abstract detailing items)

BrBnd/Oth Bnd Prgms

(identify eligible items)

Sub-Total

Other Costs %FUND *Description Requested

TOTAL

Remarks:

Approved by: County/City Engineer Date Approved by: State Aid Finance Date

I certify that: (a) Engineering & ROW costs requested above are a reimbursement for costs incurred, or a percentage of estimated costs. (b) Wage rates specified in the contract were paid and are equal or exceed the minimum hourly rates required for work on state funded projects as determined by the MN Dept. of Labor and Industry. (c) Inspection on the state-aid funded portions of this project were performed by personnel certified in accordance with state-aid directives. (d) Work required by this contract was completed in accordance with and pursuant to the terms of this contract. (e) Payment and performance bonds for the full amount of the contract have been provided with aggregate liability of the bond(s) to twice the full amount of the contract.

I certify all costs are reasonable. For finals I accept all work performance as in compliance with the approved plans and specifications. DSAE signature for Maintenance Facilities is not required on this form; prior approval was received.

/ /Approved by: District State Aid Engineer Date

/ / / /

-$ -$ -$ -$

*Other Cost Description: Right-of-Way (ROW), Engineering (ENG)-Max 25%, Maintenance Facility (MF), Force Account (FA). FA includes work performed by force labor such as work by local agencies, R/R, utility work, or contractors if not let under bids. Also agency furnished materials must include a FA agreement.

-$ -$

-$ -$

Total Oblig/Paid Requested Payments Pay at this time

-$ -$

-$ -$ -$ -$

Amount Less Previous

-$ Acct# Total Grant Amount Certif ied & Paid To Date

specify

specify

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

Total Obligated Amount Less PreviousCosts Requested Payments Pay at this time

Funding below is for this project number only. Costs for projects or agreements tied to this project should not be included on this request. A separate State Aid Payment Request must be submitted for each project number. Final reports must includea final estimate detailing quantity, unit price and extension splits for each project number. Bridge eligible items must be identified on the abstract.

Tied Projects:

Bond Co.

STATE AID PAYMENT REQUEST

Final Project Type:

Check if Bond Eligible Items are 100% Complete.

Checking the Request

Before you submit your payment request to the DSAE check the following:Sub-Total: This field will auto calculate and MUST equal the awarded bid or the current value of work certified.Total: Again these will auto calculate. Any costs in addition to the contract costs must have documentation, and the total of the documentation MUST equal the first column total. The total amount requested should make sense when you review your documentation. Less previous payments must be equal to any previously paid funds on this project. The total to be paid at this time should be reasonable and you should be able to calculate the same number from your documentation. Signatures: The payment request must be signed and dated by the local agency’s engineer. The DSAE will sign the pay request before it is forwarded to the State Aid Finance office. Payments will not be made if both parties have not signed.

MN/DOT 30172 revised June 2013

County/City Report: Partial SP SAP Project #:

Bid Opening Date: Award Date:

Local Proj. ID (opt) Contractor:

Constr. Completed Date:

Project Funding:

Contract Costs (this SAP only) %Requested

FUND

Municipal (MSAS > 5000)

Regular (CSAH)

Municipal (MSAH < 5000)

Town Bridge

Special Town Bridge

Turnback

State Park

State Aid Disaster

Local / Other

Local / Other

Federal

State Aid Bonds Applied

Credit for Local Effort (attach abstract detailing items)

BrBnd/Oth Bnd Prgms

(identify eligible items)

Sub-Total

Other Costs %FUND *Description Requested

TOTAL

Remarks:

Approved by: County/City Engineer Date Approved by: State Aid Finance Date

I certify that: (a) Engineering & ROW costs requested above are a reimbursement for costs incurred, or a percentage of estimated costs. (b) Wage rates specified in the contract were paid and are equal or exceed the minimum hourly rates required for work on state funded projects as determined by the MN Dept. of Labor and Industry. (c) Inspection on the state-aid funded portions of this project were performed by personnel certified in accordance with state-aid directives. (d) Work required by this contract was completed in accordance with and pursuant to the terms of this contract. (e) Payment and performance bonds for the full amount of the contract have been provided with aggregate liability of the bond(s) to twice the full amount of the contract.

I certify all costs are reasonable. For finals I accept all work performance as in compliance with the approved plans and specifications. DSAE signature for Maintenance Facilities is not required on this form; prior approval was received.

/ /Approved by: District State Aid Engineer Date

/ / / /

-$ -$ -$ -$

*Other Cost Description: Right-of-Way (ROW), Engineering (ENG)-Max 25%, Maintenance Facility (MF), Force Account (FA). FA includes work performed by force labor such as work by local agencies, R/R, utility work, or contractors if not let under bids. Also agency furnished materials must include a FA agreement.

-$ -$

-$ -$

Total Oblig/Paid Requested Payments Pay at this time

-$ -$

-$ -$ -$ -$

Amount Less Previous

-$ Acct# Total Grant Amount Certif ied & Paid To Date

specify

specify

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

Total Obligated Amount Less PreviousCosts Requested Payments Pay at this time

Funding below is for this project number only. Costs for projects or agreements tied to this project should not be included on this request. A separate State Aid Payment Request must be submitted for each project number. Final reports must includea final estimate detailing quantity, unit price and extension splits for each project number. Bridge eligible items must be identified on the abstract.

Tied Projects:

Bond Co.

STATE AID PAYMENT REQUEST

Final Project Type:

Check if Bond Eligible Items are 100% Complete.

QUESTIONS?