I. % ofWork

Completed To Date

(Based on Dollars)

A. List all CertifiedSubconsultants and

Suppliers

D. AgreementAmount

C. EstimatedStart/End

Date

E. Supplier at 60%(AutomaticallyCalculated)/

Broker's Fee Credit

B. Certification/Designations

G. PreviousPayments

F. Payments thisMonth

H. Total Paymentsto Date

TA-W1059 (07/2019) PAYMENTS (CONSULTANT)

Email completed form to the Office of Compliance at Compliance@thruway.ny.gov or mail to P.O. Box 189, Albany, NY 12201-0189

Consultant Name and Address Contract Goals

$

Preparer's Name (Print)

Grand Total

INSTRUCTIONS: This form must be submitted by the consultant to report actual monthly payments made to certify DBEs/MWBEs/SDVOBs. Complete and accurate forms must be submitted by the 10th of the month reflecting payments made during the previous month. Please Note: Broker Fees and Supplier Credits (60%) will be automatically calculated.

PREPARED BY:

Page 1 of 4

MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

D. No.

MBE % - $ SDVOB % - $

WBE % - $ DBE % - $

$

$

Supplier @ 60%

$MBE

WBE

DBE

SDVOB

$

$

Supplier @ 60%

$MBE

WBE

DBE

SDVOB

$

$

Supplier @ 60%

$MBE

WBE

DBE

SDVOB

$

$

Broker (Fee Only)

Broker (Fee Only)

Broker (Fee Only)

Broker (Fee Only)

Preparer's Signature

Email Address

$

%

%

%

%

$

$

$

$

$

$

$

$

$

$

$

WBE Sub Total $

Date Submitted

$DBE Sub Total

No Payments

$SDVOB Sub Total

$MBE Sub Total

$

$

$

$

$

$

$

$

$

$

$

$

%

%

%

%

-)(Phone No.

End Date

Start Date

End Date

Start Date

End Date

Start Date

End Date

Start Date

60% Payment 60% Payment 60% Payment

60% Payment 60% Payment 60% Payment

60% Payment60% Payment 60% Payment

60% Payment 60% Payment 60% Payment

Contract Value $ Contract Number

ReportingMonth / Year

TA-W1059 (07/2019) PAYMENTS (CONSULTANT)

Page 2 of 4

I. % ofWork

Completed To Date

(Based on Dollars)

A. List all Subconsultants,Suppliers and Trucking Firms

D. AgreementAmount

C. EstimatedStart/End

Date

E. Supplier at 60%(AutomaticallyCalculated)/

Broker's Fee Credit

B. Certification/ Designations

G. PreviousPayments

F. Payments thisMonth

H. Total Paymentsto Date

$MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

$

Broker (Fee Only)

$

%

$ $

No Payments

$ $ $End Date

Start Date60% Payment 60% Payment 60% Payment

$MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

$

Broker (Fee Only)

$

%

$ $

$ $ $End Date

Start Date60% Payment 60% Payment 60% Payment

$MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

$

Broker (Fee Only)

$

%

$ $

$ $ $End Date

Start Date60% Payment 60% Payment 60% Payment

$MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

$

Broker (Fee Only)

$

%

$ $

$ $ $End Date

Start Date60% Payment 60% Payment 60% Payment

$MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

$

Broker (Fee Only)

$

%

$ $

$ $ $End Date

Start Date60% Payment 60% Payment 60% Payment

$MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

$

Broker (Fee Only)

$

%

$ $

$ $ $End Date

Start Date60% Payment 60% Payment 60% Payment

$MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

$

Broker (Fee Only)

$

%

$ $

$ $ $End Date

Start Date60% Payment 60% Payment 60% Payment

D No.

TA-W1059 (07/2019) PAYMENTS (CONSULTANT)

Page 3 of 4

I. % ofWork

Completed To Date

(Based on Dollars)

A. List all Subconsultants,Suppliers and Trucking Firms

D. AgreementAmount

C. EstimatedStart/End

Date

E. Supplier at 60%(AutomaticallyCalculated)/

Broker's Fee Credit

B. Certification/ Designations

G. PreviousPayments

F. Payments thisMonth

H. Total Paymentsto Date

$MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

$

Broker (Fee Only)

$

%

$ $

No Payments

$ $ $End Date

Start Date60% Payment 60% Payment 60% Payment

$MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

$

Broker (Fee Only)

$

%

$ $

$ $ $End Date

Start Date60% Payment 60% Payment 60% Payment

$MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

$

Broker (Fee Only)

$

%

$ $

$ $ $End Date

Start Date60% Payment 60% Payment 60% Payment

$MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

$

Broker (Fee Only)

$

%

$ $

$ $ $End Date

Start Date60% Payment 60% Payment 60% Payment

$MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

$

Broker (Fee Only)

$

%

$ $

$ $ $End Date

Start Date60% Payment 60% Payment 60% Payment

$MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

$

Broker (Fee Only)

$

%

$ $

$ $ $End Date

Start Date60% Payment 60% Payment 60% Payment

$MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

$

Broker (Fee Only)

$

%

$ $

$ $ $End Date

Start Date60% Payment 60% Payment 60% Payment

D No.

TA-W1059 (07/2019) PAYMENTS (CONSULTANT)

Page 4 of 4

I. % ofWork

Completed To Date

(Based on Dollars)

A. List all Subconsultants,Suppliers and Trucking Firms

D. AgreementAmount

C. EstimatedStart/End

Date

E. Supplier at 60%(AutomaticallyCalculated)/

Broker's Fee Credit

B. Certification/Designations

G. PreviousPayments

F. Payments thisMonth

H. Total Paymentsto Date

$MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

$

Broker (Fee Only)

$

%

$ $

No Payments

$ $ $End Date

Start Date60% Payment 60% Payment 60% Payment

$MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

$

Broker (Fee Only)

$

%

$ $

$ $ $End Date

Start Date60% Payment 60% Payment 60% Payment

$MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

$

Broker (Fee Only)

$

%

$ $

$ $ $End Date

Start Date60% Payment 60% Payment 60% Payment

$MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

$

Broker (Fee Only)

$

%

$ $

$ $ $End Date

Start Date60% Payment 60% Payment 60% Payment

$MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

$

Broker (Fee Only)

$

%

$ $

$ $ $End Date

Start Date60% Payment 60% Payment 60% Payment

$MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

$

Broker (Fee Only)

$

%

$ $

$ $ $End Date

Start Date60% Payment 60% Payment 60% Payment

$MBE

WBE

DBE

SDVOB

Supplier @ 60%

$

$

Broker (Fee Only)

$

%

$ $

$ $ $End Date

Start Date60% Payment 60% Payment 60% Payment

D No.