LG Entity Name
LG Entity Address
LG Entity Phone Number
Date
RE:
Project:
CSJ:
HWY:
County:
District Engineer
TxDOT District
District Address
Dear District Engineer:
On behalf of __LG Entity__, I hereby certify that the quantities and values for Materials
on Hand indicated on the attached TxDOT Forms 1914 and 1915 executed by the
Contractor and included in the Request for Payment (dated_________) have been
reviewed by representatives of the __LG Entity__ and are true and correct. The amount
requested includes only the invoice cost of acceptable nonperishable materials that
have not been used in the work and have been delivered to the work location or are in
acceptable storage places. Only materials that have been sampled, tested, approved, or
certified, and are ready for incorporation into the work are included in this request. Only
materials which are completely constructed or fabricated on the Contractor’s order for
this project (and are so marked) and on which an approved test report has been issued
are included.
All related project records are subject to review by TxDOT and will be retained in
accordance with TxDOT’s record retention policy.
Texas P.E. Seal
Date
___LG Engineer Signature________
LG Engineer Printed Name and Title