Oklahoma Department of Transportation
Final Estimate Affidavit

Contract ID: 120285   Estimate Number: 0004 , Final     Spec Year: 2009
Primary JP: 20997(17)   Residency: PURCELL (03200)     Contract No: 810390
Date Created: 09/19/2013   Contractor FEI: 272935343     Account No: 400300

Project Number(s): STPY-214C(013)RW
Contract Description: RIGHT-OF-WAY CLEARANCE US-77: FROM 4.05 MILES NORTH OF SH-39, EXTEND NORTH THROUGH SLAUGHTERVILLE.
Primary County: CLEVELAND              
Name of Road: US-77              
Prime Contractor: ROBIN HAUSNER HOUSE MOVERS & DEMOLITION, LLC           Time Charged: 150.00
    R.R. 2 BOX 42-50           Time Allowed: 180.00
    SPERRY , OK   74073           Percent Time: 83.33 %

  Paid To Date: $37,016.20 Payable This Statement: $0.00

CONTRACTOR AFFIDAVIT
STATE OF ___________________ )  
  )      
COUNTY OF __________________ )  
The undersigned contractor or duly authorized agent, of lawful age, being first duly sworn, on oath say that this claim is true and correct.
Affiant further states that the work, services or materials as shown by this claim have been completed or supplied in accordance with the plans, specifications, orders, requests and all other terms of the contract. Affiant further states that (s)he is duly authorized agent of the contractor for the purpose of certifying the facts pertaining to the giving of things of value to government personnel in order to procure the contract or obtain payment; that (s)he is fully aware of the facts and circumstances surrounding the making of the contract and has been personally and directly involved in the proceedings leading to the procurement of the contract and the filing of this claim; and, neither the contractor nor anyone subject to the contractor's direction or control has been paid, given or donated or agreed to pay, give or donate to any officer or employee of the State of Oklahoma any money or other thing of value, either directly or
indirectly, in procuring the contract or obtaining payment. The affiant further certifies that all laborers, mechanics, apprentices and trainees employed by him/her or by any subcontractor performing work under the contract on the project have been paid wages at rates not less than those required by the contract provisions, and that the work performed by each such laborer, mechanic, apprentice or trainee conformed to the classifications set forth in the contract or training program provisions applicable to the wage rate paid.
Affiant hereby agrees that Contractor will accept this estimate as full compensation for all money due Contractor by the Department of Transportation, and hereby relinquish all claims, either in contract or in tort, which have arisen or which might arise out of the construction of said project. That to the best of my knowledge and belief, all indebtedness for labor, materials, fuel, equipment, equipment rental, parts, supplies, insurance premiums, and claims for items not specifically mentioned, which are attributable to performance of the work on this project or which were incorporated therein in any manner, have been paid in full, and that there are not now any presently outstanding, unpaid claims for such indebtedness; that my position with the company is such, that if there were any such outstanding claims of the nature specified herein, I would ordinarily be aware of them.
Further affiant sayeth not.                                
ROBIN HAUSNER HOUSE MOVERS & DEMOLITION, LLC                               
 
_________________________________________________
Affiant Signature
 
_________________________________________________
Affiant Printed Name
                          PE Seal
_________________________________________________
Affiant Company Position
Subscribed and sworn to before me this ______ day of ____________, 20____
My Commission Number: ____________ My Commission Expires: ______________
   
_________________________________________________              
_________________________________________________
                    Professional Engineer Signature
              Oklahoma Department of Transportation
Corporate Seal
Notary Seal                  

Oklahoma Department of Transportation
Final Estimate Summary
Created:    09/19/2013
Contract ID: 120285   Estimate Number: 0004     Contract No: 810390
Residency: PURCELL (03200)   Estimate Type: Final     Account No: 400300

Project Number(s): STPY-214C(013)RW
Primary Job Piece No: 20997(17)
Contract Description: RIGHT-OF-WAY CLEARANCE US-77: FROM 4.05 MILES NORTH OF SH-39, EXTEND NORTH THROUGH SLAUGHTERVILLE.
Primary County: CLEVELAND              
Name of Road: US-77              
Prime Contractor: ROBIN HAUSNER HOUSE MOVERS & DEMOLITION, LLC              
    R.R. 2 BOX 42-50              
    SPERRY , OK   74073              
Surety Company: AMERICAN SAFETY CASUALTY INSURANCE CO.              

Date Let: 08/16/2012 NTP Effective Date: 10/22/2012 Pay Period: 07/01/2013  TO  08/26/2013
Date Awarded: 09/10/2012 Date Work Began: 11/17/2012 Original Contract Time: 180
Date Contract Executed: 09/27/2012 Date Time Stopped: 05/28/2013 Current Time Charged: 150.00
Date NTP Issued: 10/02/2012 Completion Date: 05/28/2013 Current Time Allowed: 180.00
General Liability Expires: 07/01/2013 Workman's Comp Expires: 07/01/2013 Percent Time Used: 83.33 %
Specification Year: 2009        

Current Contract Amount: $37,016.20 Total to Date Prev to Date This Estimate
Bid Amount: $32,188.00 Participating: $37,016.20 $37,016.20 $0.00
Percent Complete: 100 % Non Participating: $0.00 $0.00 $0.00
Funds Available: $0.00 Total Earnings: $37,016.20 $37,016.20 $0.00
Unearned Balance: $-4,828.20 Stockpiled Materials: $0.00 $0.00 $0.00
Gross Earnings: $37,016.20 $37,016.20 $0.00
Other Adjustments: $0.00 $0.00 $0.00
Liq Dam/Disincentive: $0.00 $0.00 $0.00
TOTAL: $37,016.20 $37,016.20 $0.00

Estimate Adjustment Detail

Contract ID: 120285   Estimate Number: 0004     Primary JP: 20997(17)



CHANGE ORDER HISTORY
Change Order Nbr. Change Order Description Status Approval Date Contract Time Adjustment Total Change Order Amount
001 C.O. FOR ADDITIONAL WORK. Approved 06/18/2013 0.0 $4,828.20


STOCKPILE PAYMENT HISTORY
Project Line Nbr Stockpile Description Adjustment Type Estimate Nbr Adjusted Amount
No material stockpiles have been created for this contract.
Subtotals For Stockpile Payments $0.00


LIQUIDATED DAMAGES HISTORY
Adjustment Description Estimate Nbr Time Units Rate Adjustment Amount
No liquidated damages have been assessed on this contract.
Subtotals For Liquidated Damages $


CONTRACT ADJUSTMENTS HISTORY
Adjustment Description Estimate Nbr Adjustment Amount
No general contract adjustments have been created on this contract.
Subtotals For Contract Adjustments $0.00


LINE ITEM ADJUSTMENT HISTORY
Project Item Nbr Line Item Description Adjustment Type Estimate Nbr Adj Quantity Unit Price Adjusted Amount
No line item adjustments have been created on this contract.
Subtotals For Line Item Adjustments $0.00


MILESTONE INFORMATION
Milestone Number Milestone Description Start Date End Date Current Time Allowed Rate Milestone Closed
No milestones exist for this contract.


MILESTONE ADJUSTMENTS
Milestone Number Milestone Adjustment Description Estimate Nbr Total
No milestones adjustments exist for this contract.
Subtotals For Milestones $

Line Item Detail

Contract ID: 120285   Estimate Number: 0004     Primary JP: 20997(17)



Line Item Number Item Description Item Number Units Bid Qty Current Quantity Quantity Paid This Est. Quantity Paid To Date Unit Price Amount Paid This Est. Amount Paid To Date
Fed/State Project Number:    STPY-214C(013)RW Project:    20997(17) Category:    0640/CONSTRUCTION
0001 RIGHT-OF-WAY CLEARANCE 619(G) 0094 LSUM 1.000 1.000   1.000 $32,188.00 $0.00 $32,188.00
8000 RIGHT-OF-WAY CLEARANCE 619(G) 0094 LSUM 0.000 1.000   1.000 $4,828.20 $0.00 $4,828.20
Subtotals For Category     0640/CONSTRUCTION    $0.00 $37,016.20
Subtotals For Project STPY-214C(013)RW /20997(17) $0.00 $37,016.20