Sample Monthly Billing Worksheet Cover Sheet
{Insert Date}
{Insert TxDOT Area Office Address}
Project Name: {Enter Project Description}
Project Number: {Enter Project Number}
CSJ: {Enter CSJ}
Service Period: {Enter beginning date} to {Enter ending date}
Total Costs Incurred This Period
Total Eligible Costs
$
$
Ineligible Costs
$
Local Participation of El. Costs (______ %) $
Total Local Participation
$
Federal Participation of El. Costs (________ %)$
TxDOT Participation of El. Costs (
%) $
5% Retainage withheld of Federal Request $
Total Amount of Request
$
Please process a reimbursement request for the above project in the amount of $
____________________. Attached are all required supporting documents and reports to support
these charges.
If you have any questions, please contact {insert contact person’s name} at {enter phone
number}.
Thank you.
{Enter Signature Line}
Enclosed:








Billing Worksheet w/support documents for all charges
Form 2177 Prompt Payment form
Form 2423 Local Government Construction Inspection Report
Change Orders (# ---)
Contract Time Statement
Material on Hand Forms 1914 and 1915
DBE Reports
Other _______________
Sample Final Payment Request Cover Sheet
{Insert Date}
{Insert TxDOT Area Office Address}
Project Name: {Enter Project Description}
Project Number: {Enter Project Number}
CSJ: {Enter CSJ}
Service Period: {Enter beginning date} to {Enter ending date}
Request/Estimate: Final
Total Costs Incurred This Period
Total Eligible Costs
$
$
Ineligible Costs
$
Local Participation of El. Costs (______ %) $
Total Local Participation
$
Federal Participation of El. Costs (________ %)$
TxDOT Participation of El. Costs (
%) $
Release of Previously Withheld Retainage
Total Amount of Request
$
$
Please process a reimbursement request for the above project in the amount of $
____________________. Attached are all required supporting documents and reports to support
these charges.
If you have any questions, please contact {insert contact person’s name} at {enter phone
number}.
Thank you.
{Enter Signature Line}
Enclosed:











Billing Worksheet w/support documents for all charges
Form 2177 Prompt Payment form
Form 2423 Local Government Construction Inspection Report
Contract Time Statement
Final DBE Report
TDLR Inspection Verification
Certification Letter
Completed Local Let Project Guidelines Document
Final Project Records Review Report
Project Records for Review (To be returned to LG)
Other _______________