EXTERNAL PROVIDER BILLING STATEMENTF-ACT-001 | Rev.

3 | 01/25/2021 | Page 1 of 2

Contractor: S&C WATERWORKS SERVICES Date: 6-Mar-21

JC No.: 2065 EPBS:
Project Code: ACI -241 JCS#:
Project Name:
18HD-0109 - CONSTRUCTION/REHABILITATION/UPGRADING OF SEVERO M.
VERALLO PROVINCIAL HOSPITAL, BOGO CITY, CEBU C Amount: ₱ 80,000.00

ADVANCED PAYMENT PERCENT (%) AMOUNT CONSTRUCTION HEAD

(SIGNATURE)
Downpayment
Retention

SUBCON SITE ENGINEER / PIC QS

PROGRESS
% Amount % Amount % Amount

To Date: 10.10% 10.10% ₱ 8,080.00 10.10% ₱ 8,080.00

Previous: 0.00% 0.00% ₱ - 0.00% ₱ -
This Period: 10.10% 10.10% ₱ 8,080.00 10.10% ₱ 8,080.00
Scheduled: _______ 14.29% Signature:
Slippage: ________ -4.19% Name: S&C WATERWORKS SERVICES ACE JOEMARIE LEGASPINA
# of Days: _______________ Date: 6-Mar-21 6-Mar-21
TO BE FILLED UP BY ACCOUNTING DEPARTMENT
Collectable Payment ₱
Less: Deduction Rate
Expanded Witholding Tax
Recoupment
Retention
Liquidated Damages
Other: (Pls. Specify)
Total Deductions ₱
Net Collectable Payment ₱

Prepared by: Bookkeeper Reviewed by: Accounting Supervisor

Signature over Printed Name Date Signature over Printed Name Date

MINIMUM REQUIRED ATTACHMENTS FOR EXTERNAL PROVIDERS WHOSE TERMS OF PAYMENT WEEKLY & MONTHLY:
1 DOWNPAYMENT 3 100% COMPLETION
1.1 F-ACT-001 External Provider Billing Statement 3.1 F-ACT-001 External Provider Billing Statement
1.2 Notice of Award (NOA) 3.2 F-OPR-009 Subcrontractors Summary of Work Accomplishment
1.3 Notice to Proceed (NTP) 3.3 Keyplan indicating the accomplished work
1.4 F-PUR-006 Job Contract 3.4 Geotagged Progress Photos (Before and After) pers cope of work
1.5 Mobilization Photos 3.5 Approved Work request Form
Note: In case of no downpayment, the above-mentioned requirements must be attached to the first progress
billing. 3.6 Certificate of Completion
2 BILLING AND ONWARDS
2.1 F-ACT-001 External Provider Billing Statement 2.5 F-OPR-017 JC Time Extension Request Form, if applicable
2.2 F-OPR-009 Subcrontractors Summary of Work Accomplishment (SWA) 2.6 Copy of previous External Provider Billing Statement & SWA
2.3 Geotagged Progress photos (Before and After) per scope of work 2.7 Keyplan indicating the accomplished work
2.4 Material Test Result, if applicable 2.8 Approved Work Request Form
4 RETENTION
4.1 F-ACT-001 External Provider Billing Statement 4.3 Copy of previous External Provider Billing Statement
4.2 Certificate of Acceptance

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Contractor: S&C WATERWORKS SERVICES Date: 6-Mar-21
JC No.: 2065 EPBS:
Project Code: ACI -241
18HD-0109 - CONSTRUCTION/REHABILITATION/UPGRADING OF SEVERO M. JCS#:
Project Name: VERALLO PROVINCIAL HOSPITAL, BOGO CITY, CEBU C Amount: ₱ 3,400,000.00
SUBCON SITE ENGINEER / PIC QS
PROGRESS
% Amount % Amount % Amount
To Date: 10.10% 10.10% ₱ 8,080.00 10.10% ₱ 8,080.00
Previous: 0.00% 0.00% ₱ - 0.00% ₱ -
This Period: 10.10% 10.10% ₱ 8,080.00 10.10% ₱ 8,080.00
Scheduled: ______ 14.29% Signature:
Slippage: ________ -4.19% Name: S&C WATERWORKS SERVICES ACE JOEMARIE LEGASPINA
# of Days: _________ Date: 6-Mar-21 6-Mar-21
TO BE FILLED UP BY ACCOUNTING DEPARTMENT
Collectable Payment ₱
Less: Deduction Rate
Expanded Witholding Tax
Recoupment
Retention
Liquidated Damages
Other: (Pls. Specify)
Total Deductions ₱
Net Collectable Payment ₱
Prepared by: Bookkeeper Reviewed by: Accounting Supervisor

Signature over Printed Name Date Signature over Printed Name Date
EXTERNAL PROVIDER BILLING STATEMENTF-ACT-001 | Rev. 3 | 01/25/2021 | Page 2 of 2

Contractor: S&C WATERWORKS SERVICES Date: August 23, 2021

JC No.: 2065 EPBS:
Project Code: ACI -241 JCS#:
Project Name:
18HD-0109 - CONSTRUCTION/REHABILITATION/UPGRADING OF SEVERO M.
VERALLO PROVINCIAL HOSPITAL, BOGO CITY, CEBU C Amount: ₱ 80,000.00

ADVANCED PAYMENT PERCENT (%) AMOUNT CONSTRUCTION HEAD

(SIGNATURE)
Downpayment
Retention

SUBCON SITE ENGINEER / PIC QS

PROGRESS
% Amount % Amount % Amount

To Date: 90.00% 90.00% ₱ 72,000.00 90.00% ₱ 72,000.00

Previous: 18.10% 18.10% ₱ 14,480.00 18.10% ₱ 14,480.00
This Period: 71.90% 71.90% ₱ 57,520.00 71.90% ₱ 57,520.00
Scheduled: _______ 14.29% Signature:
Slippage: ________ 75.71% Name: S&C WATERWORKS SERVICES
# of Days: _______________ Date: August 23, 2021 August 23, 2021
TO BE FILLED UP BY ACCOUNTING DEPARTMENT
Collectable Payment ₱
Less: Deduction Rate
Expanded Witholding Tax
Recoupment
Retention
Liquidated Damages
Other: (Pls. Specify)
Total Deductions ₱
Net Collectable Payment ₱

Prepared by: Bookkeeper Reviewed by: Accounting Supervisor

Signature over Printed Name Date Signature over Printed Name Date

MINIMUM REQUIRED ATTACHMENTS FOR EXTERNAL PROVIDERS WHOSE TERMS OF PAYMENT WEEKLY & MONTHLY:
1 DOWNPAYMENT 3 100% COMPLETION
1.1 F-ACT-001 External Provider Billing Statement 3.1 F-ACT-001 External Provider Billing Statement
1.2 Notice of Award (NOA) 3.2 F-OPR-009 Subcrontractors Summary of Work Accomplishment
1.3 Notice to Proceed (NTP) 3.3 Keyplan indicating the accomplished work
1.4 F-PUR-006 Job Contract 3.4 Geotagged Progress Photos (Before and After) pers cope of work
1.5 Mobilization Photos 3.5 Approved Work request Form
Note: In case of no downpayment, the above-mentioned requirements must be attached to the first progress
billing. 3.6 Certificate of Completion
2 BILLING AND ONWARDS
2.1 F-ACT-001 External Provider Billing Statement 2.5 F-OPR-017 JC Time Extension Request Form, if applicable
2.2 F-OPR-009 Subcrontractors Summary of Work Accomplishment (SWA) 2.6 Copy of previous External Provider Billing Statement & SWA
2.3 Geotagged Progress photos (Before and After) per scope of work 2.7 Keyplan indicating the accomplished work
2.4 Material Test Result, if applicable 2.8 Approved Work Request Form
4 RETENTION
4.1 F-ACT-001 External Provider Billing Statement 4.3 Copy of previous External Provider Billing Statement
4.2 Certificate of Acceptance

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Contractor: S&C WATERWORKS SERVICES Date: August 23, 2021
JC No.: 2065 EPBS:
Project Code: ACI -241
18HD-0109 - CONSTRUCTION/REHABILITATION/UPGRADING OF SEVERO M. JCS#:
Project Name: VERALLO PROVINCIAL HOSPITAL, BOGO CITY, CEBU C Amount: ₱ 80,000.00
SUBCON SITE ENGINEER / PIC QS
PROGRESS
% Amount % Amount % Amount
To Date: 90.00% 90.00% ₱ 72,000.00 90.00% ₱ 72,000.00
Previous: 18.10% 18.10% ₱ 14,480.00 18.10% ₱ 14,480.00
This Period: 71.90% 71.90% ₱ 57,520.00 71.90% ₱ 57,520.00
Scheduled: ______ 14.29% Signature:
Slippage: ________ 75.71% Name: S&C WATERWORKS SERVICES
# of Days: _________ Date: August 23, 2021 August 23, 2021
TO BE FILLED UP BY ACCOUNTING DEPARTMENT
Collectable Payment ₱
Less: Deduction Rate
Expanded Witholding Tax
Recoupment
Retention
Liquidated Damages
Other: (Pls. Specify)
Total Deductions ₱
Net Collectable Payment ₱
Prepared by: Bookkeeper Reviewed by: Accounting Supervisor

Signature over Printed Name Date Signature over Printed Name Date