Hud 51001 Form – Fill Out and Use This PDF

Submit original and one copy to the Public Housing Agency. Complete instructions are on the back of this form.

Public reporting burden for this collection of information is estimated to average 3.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of in formation. This agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless that collecton displays a valid OMB control number.

This information is collected under the authority of Section 6(c) of the U.S Housing Act of l937 and HUD regulations. HAs are responsible for contract administration to ensure that the work for project development is done in accordance with State laws and HUD requirements. The contractor/subcontractor reports provide details and summaries on payments, change orders, and schedule of materials stored for the project The information will be used to ensure that the total development costs, identified in the ACC, are kept as low as possible and consistent with HUD construction req uirements. Responses to the collection are necessary to obtain a benefit. The information requested does not lend itself to confidentiality.

Location of Project	Project Number
Name of Contractor	Contract Number

Item Number	Description of Item	Completed to Date
(1)	(2)	(3)
		$

Value of Contract Work Completed to Date (Transfer this total to line 5 on back of this sheet)

Previous editions are obsolete

ref. Handbooks 7417.1 & 7450.1

form HUD-51001 (3/92)

Certification of the Contractor or Duly Authorized Representative

According to the best of my knowledge and belief, I certify that all items and amounts shown on the other side of this form a re correct; that all work has been performed and material supplied in full accordance with the items and conditions of the contract between the (name of owner)

_______________________________________________________ and (contractor) ___________________________________________________________

d a t e d ( m m / d d / y y y y )

,

a n d d u l y a u t h o r i z e d d e v i a t i o n s , s u b s t i t u t i o n s , a l t e r a t i o n s , a n d a d d i t i o n s ;

that the following is a true and correct statement of the Contract Account up to and including the last day of the period covered by this estimate, and that no part of the "Balance Due This Payment" has been received.

1.	Original Contract Amount			$
Approved Change Orders:
2.	Additions (Total from Col. 3, form HUD-51002)	$	_________________
3.	Deductions (Total from Col. 5, form HUD-51002)	$	__________________________ (net) $ _________________
4.	Current Adjusted Contract Amount (line 1 plus or minus net)			$
Computation of Balance Due this Payment
5.	Value of Original Contract work completed to date (from other side of this form)			$
Completed Under Approved Change Orders
6.	Additions (from Col. 4, form HUD-51002)	$	_________________
7.	Deductions (from Col.5, form HUD-51002)	$	__________________________ (net) $ _________________
8.	Total Value of Work in Place (line 5 plus or minus net line 7)			$
9.	Less: Retainage,____________ %	$	_________________
10. Net amount earned to date (line 8 less line 9)				$

11.Less: Previously earned (line 10, last Periodic Estimate) $ _________________

12. Net amount due, work in place (line 10 less line 11)	$
Value of Materials Properly Stored
13. At close of this period (from form HUD-51004)	$
14. Less: Allowed last period	$
15. Increase (decrease) from amount allowed last period	$ ________________
16. Balance Due This Payment	$

I further certify that all just and lawful bills against the undersigned and his/her subcontractors for labor, material, and equipment employed in the performance of this contract have been paid in full in accordance with the terms and conditions of this contract, and that the undersigned and his/her subcontractors have complied with, or that there is an honest dispute with respect to, the labor provisions of this contract.

Name of ContractorSignature of Authorized Representative TitleDate (mm/dd/yyyy)

Certificate of Authorized Project Representative and of Contracting Officer

Each of us certifies that he/she has checked and verified this Periodic Estimate No. ___________ ; that to the best of his/her knowledge and belief it is a true

statement of the value of work performed and material supplied by the contractor; that all work and material included in this estimate has been inspected by him/her or by his/her authorized assistants; and that such work has been performed or supplied in full accordance with the drawings and specifications, the terms and conditions of the contract, and duly authorized deviations, substitutions, alterations, and additions, all of which have been duly approved.

Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729,

Previous editions are obsoleteref. Handbooks 7417.1 & 7450.1

form HUD-51001 (3/92) (3802)