Completing the State Aid
Payment Request
(SAPR)
Tips
• Each spring check on the State Aid Finance web
page for the current version of the State Aid Pay
Request form.
http://www.dot.state.mn.us/safinance/formsandresolutions.html
• Save your Payment Requests on a project so each
additional request can build on the previous
information for consistency.
• Include all funding on each pay request even if
you are not requesting payment on this request.
MN/DOT 30172 revised June 2013
Local Agency Information
STATE AID PAYMENT REQUEST
County/City
Report: Partial
Bid Opening Date:
The top section provides information about the local agency and
provides project identification.
County / City: Name of local agency requesting funds. An agency
cannot request payment of another agency’s funds.
Report: Refers to partial or final payment request. There may be
several partial payments through the project but should only be
one final.
Project Type: SAP projects are projects that do not have federal
funds; SP projects have federal funds.
Project Number: Use the 9 digit format.
Bid Opening: Use the date your agency opens the bids.
Award Date: Use the date your agency grants the contract to the
contractor. Some agencies refer to this as the “Letting Date”. The
Bid Opening and Award Date can be the same date.
Tied Projects: If more than one project is covered under one
contract they are “tied”. Referencing them here helps our office
if there are funding questions.
Local Project Number: Optional, used if your agency has a
numbering system different from the State Aid system.
Bond Company: This is the contractor’s bond agency named by
the contractor in the contract paperwork.
Contractor: Name of the contractor on the awarded bid
Construction Completion Date: Used only on the final payment
request, and should reflect the date that the work was certified
100% complete.
Final
Award Date:
Local Proj. ID (opt)
Project Type: SP
SAP
Project #:
Tied Projects:
Bond Co.
Contractor:
Constr. Completed Date:
Funding below is for this project number only. Costs for projects or agreements tied to this project should not be
included on this request. A separate State Aid Payment Request must be submitted for each project number. Final reports must include
a final estimate detailing quantity, unit price and extension splits for each project number. Bridge eligible items must be identified on the abstract.
Project Funding:
Contract Costs (this SAP only)
Total Obligated
Costs
%
Amount
Requested
Requested
Less Previous
Payments
Pay at this time
FUND
Municipal (MSAS > 5000)
$
-
$
-
Regular (CSAH)
$
-
$
-
Municipal (MSAH < 5000)
$
-
$
-
Town Bridge
$
-
$
-
Special Town Bridge
$
-
$
-
Turnback
$
-
$
-
State Park
$
-
$
-
State Aid Disaster
$
-
$
-
$
-
$
-
Local / Other
specify
Local / Other
specify
Federal
State Aid Bonds Applied
Credit for Local Effort
(attach abstract detailing items)
Check if Bond Eligible Items are 100% Complete.
BrBnd/Oth Bnd Prgms
(identify eligible items)
Acct#
Sub-Total
Other Costs
FUND
Total Grant Amount
$
Certified & Paid To Date
-
$
%
*Description
TOTAL
Total Oblig/Paid
$
Requested
-
-
$
Amount
Requested
Less Previous
Payments
Pay at this time
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
Remarks:
*Other Cost Description: Right-of-Way (ROW), Engineering (ENG)-Max 25%, Maintenance Facility (MF), Force Account (FA). FA includes work performed by
force labor such as work by local agencies, R/R, utility work, or contractors if not let under bids. Also agency furnished materials must include a FA
agreement.
I certify that: (a) Engineering & ROW costs requested above are a reimbursement for
costs incurred, or a percentage of estimated costs. (b) Wage rates specified in the
contract were paid and are equal or exceed the minimum hourly rates required for work
on state funded projects as determined by the MN Dept. of Labor and Industry. (c)
Inspection on the state-aid funded portions of this project were performed by
personnel certified in accordance with state-aid directives. (d) Work required by this
contract was completed in accordance with and pursuant to the terms of this contract.
(e) Payment and performance bonds for the full amount of the contract have been
provided with aggregate liability of the bond(s) to twice the full amount of the
contract.
/
Approved by: County/City Engineer
/
Date
I certify all costs are reasonable. For finals I accept all work performance as in
compliance with the approved plans and specifications. DSAE signature for
Maintenance Facilities is not required on this form; prior approval was received.
/
Approved by: District State Aid Engineer
/
Date
/
Approved by: State Aid Finance
/
Date
MN/DOT 30172 revised June 2013
Obligated Costs Column
STATE AID PAYMENT REQUEST
County/City
Report: Partial
Bid Opening Date:
This column includes funding requests for the
project named in the header. Projects are
never combined on a pay request even if they
are under the same contract. All other costs
will be listed in the “Other Costs” area .
Municipal (MSAS) is used by the Cities only.
Regular (CSAH), Municipal (CSAH), Regular
Town Bridge and Special Town Bridge are used
by counties only.
All the other funding sources can be used by
either entity.
Letting: The “Sub-Total” at the bottom of this
column MUST equal the total of the awarded
bid.
It is helpful to save this form and build each
pay request from the last so all the funding is
consistently included through the project.
Final: On the final payment request the “SubTotal” MUST now be equal to the final work
certified on the project.
Final
Award Date:
Local Proj. ID (opt)
Project Type: SP
SAP
Project #:
Tied Projects:
Bond Co.
Contractor:
Constr. Completed Date:
Funding below is for this project number only. Costs for projects or agreements tied to this project should not be
included on this request. A separate State Aid Payment Request must be submitted for each project number. Final reports must include
a final estimate detailing quantity, unit price and extension splits for each project number. Bridge eligible items must be identified on the abstract.
Project Funding:
Contract Costs (this SAP only)
Total Obligated
Costs
%
Amount
Requested
Requested
Less Previous
Payments
Pay at this time
FUND
Municipal (MSAS > 5000)
$
-
$
-
Regular (CSAH)
$
-
$
-
Municipal (MSAH < 5000)
$
-
$
-
Town Bridge
$
-
$
-
Special Town Bridge
$
-
$
-
Turnback
$
-
$
-
State Park
$
-
$
-
State Aid Disaster
$
-
$
-
$
-
$
-
Local / Other
specify
Local / Other
specify
Federal
State Aid Bonds Applied
Credit for Local Effort
(attach abstract detailing items)
Check if Bond Eligible Items are 100% Complete.
BrBnd/Oth Bnd Prgms
(identify eligible items)
Acct#
Sub-Total
Other Costs
FUND
Total Grant Amount
$
Certified & Paid To Date
-
$
%
*Description
TOTAL
Total Oblig/Paid
$
Requested
-
-
$
Amount
Requested
Less Previous
Payments
Pay at this time
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
Remarks:
*Other Cost Description: Right-of-Way (ROW), Engineering (ENG)-Max 25%, Maintenance Facility (MF), Force Account (FA). FA includes work performed by
force labor such as work by local agencies, R/R, utility work, or contractors if not let under bids. Also agency furnished materials must include a FA
agreement.
I certify that: (a) Engineering & ROW costs requested above are a reimbursement for
costs incurred, or a percentage of estimated costs. (b) Wage rates specified in the
contract were paid and are equal or exceed the minimum hourly rates required for work
on state funded projects as determined by the MN Dept. of Labor and Industry. (c)
Inspection on the state-aid funded portions of this project were performed by
personnel certified in accordance with state-aid directives. (d) Work required by this
contract was completed in accordance with and pursuant to the terms of this contract.
(e) Payment and performance bonds for the full amount of the contract have been
provided with aggregate liability of the bond(s) to twice the full amount of the
contract.
/
Approved by: County/City Engineer
/
Date
I certify all costs are reasonable. For finals I accept all work performance as in
compliance with the approved plans and specifications. DSAE signature for
Maintenance Facilities is not required on this form; prior approval was received.
/
Approved by: District State Aid Engineer
/
Date
/
Approved by: State Aid Finance
/
Date
Funding Sources
Allotments: The first 4 funding types are annual
allotments. Up to 95% of the total eligible costs can be
requested at letting.
Grants: The next 3 funding types are grants awarded
based on availability and are requested by project. Up to
95% of the total eligible costs can be requested at letting.
State Aid Disaster: Available to counties and cities on a
case by case basis when qualifying damage has occurred
to their road system. The funds are disbursed and the
SAPR is usually reporting how much of the money has
been spent. Unspent funds are returned to State Aid.
Reported Funding: These are the funds that are
“unreimbursed” project funding. We require that you
report 100% of the project funding, even if it is not State
Aid reimbursed. Local funding has 2 lines for your
convenience, we do not separate these for our purposes.
Bridge & Other Bond Funds: Bond funds will not be paid
out until eligible costs have been certified. Payment
requests can be submitted periodically as work is
completed. It is important to use the bond account
number found on your grant letter. The “Total Grant
Amount” is based on your awarded bid, not on the grant
letter. A breakdown showing eligible bridge items must
be submitted with the initial pay request and the total
grant cannot be greater than that amount. When bond
eligible work is 100% complete (not paid) check the box.
This allows us to maximize the funding. NOTE: Only 95%
of bond items are paid out until the project is “finaled”.
We will hold the remaining 5% for your project.
MN/DOT 30172 revised June 2013
STATE AID PAYMENT REQUEST
County/City
Report: Partial
Bid Opening Date:
Final
Award Date:
Local Proj. ID (opt)
Project Type: SP
SAP
Project #:
Tied Projects:
Bond Co.
Contractor:
Constr. Completed Date:
Funding below is for this project number only. Costs for projects or agreements tied to this project should not be
included on this request. A separate State Aid Payment Request must be submitted for each project number. Final reports must include
a final estimate detailing quantity, unit price and extension splits for each project number. Bridge eligible items must be identified on the abstract.
Project Funding:
Contract Costs (this SAP only)
Total Obligated
Costs
%
Amount
Requested
Requested
Less Previous
Payments
Pay at this time
FUND
Municipal (MSAS > 5000)
$
-
$
-
Regular (CSAH)
$
-
$
-
Municipal (MSAH < 5000)
$
-
$
-
Town Bridge
$
-
$
-
Special Town Bridge
$
-
$
-
Turnback
$
-
$
-
State Park
$
-
$
-
State Aid Disaster
$
-
$
-
$
-
$
-
Local / Other
specify
Local / Other
specify
Federal
State Aid Bonds Applied
Credit for Local Effort
(attach abstract detailing items)
Check if Bond Eligible Items are 100% Complete.
BrBnd/Oth Bnd Prgms
(identify eligible items)
Acct#
Sub-Total
Other Costs
FUND
Total Grant Amount
$
Certified & Paid To Date
-
$
%
*Description
TOTAL
Total Oblig/Paid
$
Requested
-
-
$
Amount
Requested
Less Previous
Payments
Pay at this time
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
Remarks:
*Other Cost Description: Right-of-Way (ROW), Engineering (ENG)-Max 25%, Maintenance Facility (MF), Force Account (FA). FA includes work performed by
force labor such as work by local agencies, R/R, utility work, or contractors if not let under bids. Also agency furnished materials must include a FA
agreement.
I certify that: (a) Engineering & ROW costs requested above are a reimbursement for
costs incurred, or a percentage of estimated costs. (b) Wage rates specified in the
contract were paid and are equal or exceed the minimum hourly rates required for work
on state funded projects as determined by the MN Dept. of Labor and Industry. (c)
Inspection on the state-aid funded portions of this project were performed by
personnel certified in accordance with state-aid directives. (d) Work required by this
contract was completed in accordance with and pursuant to the terms of this contract.
(e) Payment and performance bonds for the full amount of the contract have been
provided with aggregate liability of the bond(s) to twice the full amount of the
contract.
/
Approved by: County/City Engineer
/
Date
I certify all costs are reasonable. For finals I accept all work performance as in
compliance with the approved plans and specifications. DSAE signature for
Maintenance Facilities is not required on this form; prior approval was received.
/
Approved by: District State Aid Engineer
/
Date
/
Approved by: State Aid Finance
/
Date
MN/DOT 30172 revised June 2013
STATE AID PAYMENT REQUEST
Funding Requested
County/City
Report: Partial
Bid Opening Date:
Local Proj. ID (opt)
The yellow shaded fields must be entered and the
other fields will auto calculate.
Project Type: SP
SAP
Project #:
Tied Projects:
Bond Co.
Contractor:
Constr. Completed Date:
Funding below is for this project number only. Costs for projects or agreements tied to this project should not be
included on this request. A separate State Aid Payment Request must be submitted for each project number. Final reports must include
a final estimate detailing quantity, unit price and extension splits for each project number. Bridge eligible items must be identified on the abstract.
Project Funding:
Contract Costs (this SAP only)
Allotted Funds: As long as there is a balance in the
allotment account these funds will be paid at the
percentage requested up to 95% and the remaining
5% will be encumbered. “Short Payments” occur
when the allotment balance is insufficient. Available
funds will be released up to the requested amount
but nothing will be encumbered in an advance
situation. The unpaid portion will be released when
the new allotment comes in or a resolution to
advance is received.
Granted Funds: After the letting up to 95% of the
eligible costs can be requested and paid. Any
remaining funds up to the original grant amount will
remain allocated to the project until it is finaled.
• Special Town Bridge granted on a project will be
used after the Regular Town Bridge is depleted
and the funds should be applied for that way.
• Turnback and State Park funds are generally
available for project expenses up to the grant
approved amount. They are not usually tied to
specific spec items like bridge funds are.
Final
Award Date:
Total Obligated
Costs
%
Amount
Requested
Requested
Less Previous
Payments
Pay at this time
FUND
Municipal (MSAS > 5000)
$
-
$
-
Regular (CSAH)
$
-
$
-
Municipal (MSAH < 5000)
$
-
$
-
Town Bridge
$
-
$
-
Special Town Bridge
$
-
$
-
Turnback
$
-
$
-
State Park
$
-
$
-
State Aid Disaster
$
-
$
-
$
-
$
-
Local / Other
specify
Local / Other
specify
Federal
State Aid Bonds Applied
Credit for Local Effort
(attach abstract detailing items)
Check if Bond Eligible Items are 100% Complete.
BrBnd/Oth Bnd Prgms
(identify eligible items)
Sub-Total
Other Costs
FUND
Total Grant Amount
Acct#
$
Certified & Paid To Date
-
$
%
*Description
TOTAL
Total Oblig/Paid
$
-
-
$
Amount
Requested
Requested
Less Previous
Payments
Pay at this time
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
Remarks:
*Other Cost Description: Right-of-Way (ROW), Engineering (ENG)-Max 25%, Maintenance Facility (MF), Force Account (FA). FA includes work performed by
force labor such as work by local agencies, R/R, utility work, or contractors if not let under bids. Also agency furnished materials must include a FA
agreement.
I certify that: (a) Engineering & ROW costs requested above are a reimbursement for
costs incurred, or a percentage of estimated costs. (b) Wage rates specified in the
contract were paid and are equal or exceed the minimum hourly rates required for work
on state funded projects as determined by the MN Dept. of Labor and Industry. (c)
Inspection on the state-aid funded portions of this project were performed by
personnel certified in accordance with state-aid directives. (d) Work required by this
contract was completed in accordance with and pursuant to the terms of this contract.
(e) Payment and performance bonds for the full amount of the contract have been
provided with aggregate liability of the bond(s) to twice the full amount of the
contract.
/
Approved by: County/City Engineer
/
Date
I certify all costs are reasonable. For finals I accept all work performance as in
compliance with the approved plans and specifications. DSAE signature for
Maintenance Facilities is not required on this form; prior approval was received.
/
Approved by: District State Aid Engineer
/
Date
/
Approved by: State Aid Finance
/
Date
MN/DOT 30172 revised June 2013
STATE AID PAYMENT REQUEST
County/City
Reported Funding
These funds will not calculate into a payment
amount because they are not reimbursable
from State Aid.
Local / Other: These can be from another state
entity, local community, or tribal government.
They do not have to be broken out for our
purposes.
Federal funds are reimbursed by State Aid, but
they must be requested through the Delegated
Contract Process (DCP) on the State Aid Finance
webpage. This process is completed as eligible
costs are incurred.
State Aid Bonds (Local Agency Bonds) provides
a place to report “applying” bond funds already
received to an eligible project. This must be
done if a local agency issues a bond and uses
their State Aid Allotments for the repayment.
Credit For Local Effort will probably be
removed from this form as the new “Needs”
program is developed. At this time it is not
being considered to be a part of future needs
and our form will change when we know for
certain.
Report: Partial
Bid Opening Date:
Final
Award Date:
Local Proj. ID (opt)
Project Type: SP
SAP
Project #:
Tied Projects:
Bond Co.
Contractor:
Constr. Completed Date:
Funding below is for this project number only. Costs for projects or agreements tied to this project should not be
included on this request. A separate State Aid Payment Request must be submitted for each project number. Final reports must include
a final estimate detailing quantity, unit price and extension splits for each project number. Bridge eligible items must be identified on the abstract.
Project Funding:
Contract Costs (this SAP only)
Total Obligated
Costs
%
Amount
Requested
Requested
Less Previous
Payments
Pay at this time
FUND
Municipal (MSAS > 5000)
$
-
$
-
Regular (CSAH)
$
-
$
-
Municipal (MSAH < 5000)
$
-
$
-
Town Bridge
$
-
$
-
Special Town Bridge
$
-
$
-
Turnback
$
-
$
-
State Park
$
-
$
-
State Aid Disaster
$
-
$
-
$
-
$
-
Local / Other
specify
Local / Other
specify
Federal
State Aid Bonds Applied
Credit for Local Effort
(attach abstract detailing items)
Check if Bond Eligible Items are 100% Complete.
BrBnd/Oth Bnd Prgms
(identify eligible items)
Sub-Total
Other Costs
FUND
Total Grant Amount
Acct#
$
Certified & Paid To Date
-
$
%
*Description
TOTAL
Total Oblig/Paid
$
-
-
$
Amount
Requested
Requested
Less Previous
Payments
Pay at this time
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
Remarks:
*Other Cost Description: Right-of-Way (ROW), Engineering (ENG)-Max 25%, Maintenance Facility (MF), Force Account (FA). FA includes work performed by
force labor such as work by local agencies, R/R, utility work, or contractors if not let under bids. Also agency furnished materials must include a FA
agreement.
I certify that: (a) Engineering & ROW costs requested above are a reimbursement for
costs incurred, or a percentage of estimated costs. (b) Wage rates specified in the
contract were paid and are equal or exceed the minimum hourly rates required for work
on state funded projects as determined by the MN Dept. of Labor and Industry. (c)
Inspection on the state-aid funded portions of this project were performed by
personnel certified in accordance with state-aid directives. (d) Work required by this
contract was completed in accordance with and pursuant to the terms of this contract.
(e) Payment and performance bonds for the full amount of the contract have been
provided with aggregate liability of the bond(s) to twice the full amount of the
contract.
/
Approved by: County/City Engineer
/
Date
I certify all costs are reasonable. For finals I accept all work performance as in
compliance with the approved plans and specifications. DSAE signature for
Maintenance Facilities is not required on this form; prior approval was received.
/
Approved by: District State Aid Engineer
/
Date
/
Approved by: State Aid Finance
/
Date
Bridge Funds
All pay requests for Bridge Funds must include a
breakdown of eligible bridge costs and ineligible bridge
costs in the same format as the Engineer’s Estimate.
Town Bridge (County Only) Regular funds are always
used first to pay the eligible bridge items on a
township bridge project. Once these are depleted and
the local share has been applied other Special Town
Bridge, bond, or local funds can be used.
Bridge & Other Bond funds do not allow you to
request a percentage to pay because you request
after the work is certified. The amount the local
agency has certified and paid is 100% eligible to be
reimbursed up to the authorized grant amount. You
will only be paid 95% of these costs until the project is
finaled.
The “Total Grant Amount” is based on the awarded
bid’s eligible bridge costs not on the original grant
amount.
The Account number of the bond funds is provided to
you on your award letter and should be referenced on
the pay request. It insures that the bond funds are
paid from the correct account when the pay request is
processed.
When the bond eligible items are 100% complete
check the box on the payment request. This allows
the unused funds to be reallocated.
MN/DOT 30172 revised June 2013
STATE AID PAYMENT REQUEST
County/City
Report: Partial
Bid Opening Date:
Final
Award Date:
Local Proj. ID (opt)
Project Type: SP
SAP
Project #:
Tied Projects:
Bond Co.
Contractor:
Constr. Completed Date:
Funding below is for this project number only. Costs for projects or agreements tied to this project should not be
included on this request. A separate State Aid Payment Request must be submitted for each project number. Final reports must include
a final estimate detailing quantity, unit price and extension splits for each project number. Bridge eligible items must be identified on the abstract.
Project Funding:
Contract Costs (this SAP only)
Total Obligated
Costs
%
Amount
Requested
Requested
Less Previous
Payments
Pay at this time
FUND
Municipal (MSAS > 5000)
$
-
$
-
Regular (CSAH)
$
-
$
-
Municipal (MSAH < 5000)
$
-
$
-
Town Bridge
$
-
$
-
Special Town Bridge
$
-
$
-
Turnback
$
-
$
-
State Park
$
-
$
-
State Aid Disaster
$
-
$
-
$
-
$
-
Local / Other
specify
Local / Other
specify
Federal
State Aid Bonds Applied
Credit for Local Effort
Check if Bond Eligible Items are 100% Complete.
(attach abstract detailing items)
BrBnd/Oth Bnd Prgms
(identify eligible items)
Sub-Total
Other Costs
FUND
Total Grant Amount
Acct#
$
Certified & Paid To Date
-
$
%
*Description
TOTAL
Total Oblig/Paid
$
-
-
$
Amount
Requested
Requested
Less Previous
Payments
Pay at this time
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
Remarks:
*Other Cost Description: Right-of-Way (ROW), Engineering (ENG)-Max 25%, Maintenance Facility (MF), Force Account (FA). FA includes work performed by
force labor such as work by local agencies, R/R, utility work, or contractors if not let under bids. Also agency furnished materials must include a FA
agreement.
I certify that: (a) Engineering & ROW costs requested above are a reimbursement for
costs incurred, or a percentage of estimated costs. (b) Wage rates specified in the
contract were paid and are equal or exceed the minimum hourly rates required for work
on state funded projects as determined by the MN Dept. of Labor and Industry. (c)
Inspection on the state-aid funded portions of this project were performed by
personnel certified in accordance with state-aid directives. (d) Work required by this
contract was completed in accordance with and pursuant to the terms of this contract.
(e) Payment and performance bonds for the full amount of the contract have been
provided with aggregate liability of the bond(s) to twice the full amount of the
contract.
/
Approved by: County/City Engineer
/
Date
I certify all costs are reasonable. For finals I accept all work performance as in
compliance with the approved plans and specifications. DSAE signature for
Maintenance Facilities is not required on this form; prior approval was received.
/
Approved by: District State Aid Engineer
/
Date
/
Approved by: State Aid Finance
/
Date
Other Costs
Report project expenses that are not part of the
contract costs here.
Indicate the funding source the costs will be paid
from.
Incurred costs will be paid at 100% and estimated
costs will be paid at 95%.
The only descriptions used at State Aid are ROW,
ENG, FA, and MF please use these codes on your
pay requests.
Right of Way (ROW): Submit clear documentation
of the payments or costs to acquire ROW. A listing
of these can be found on the SALT website.
Engineering (ENG): Submit documentation of force
labor costs or an invoice from a consultant.
Combine preliminary and construction
engineering into one line unless there are
multiple funding sources.
Force Account (FA): Submit documentation of
force labor costs or an invoice from an external
source like utilities or railroad. These costs also
require a Force Account Agreement to be
completed and submitted with the pay request.
Maintenance Facilities (MF): (County Only) Submit
progress billings from the contract.
MN/DOT 30172 revised June 2013
STATE AID PAYMENT REQUEST
County/City
Report: Partial
Bid Opening Date:
Final
Award Date:
Local Proj. ID (opt)
Project Type: SP
SAP
Project #:
Tied Projects:
Bond Co.
Contractor:
Constr. Completed Date:
Funding below is for this project number only. Costs for projects or agreements tied to this project should not be
included on this request. A separate State Aid Payment Request must be submitted for each project number. Final reports must include
a final estimate detailing quantity, unit price and extension splits for each project number. Bridge eligible items must be identified on the abstract.
Project Funding:
Contract Costs (this SAP only)
Total Obligated
Costs
%
Amount
Requested
Requested
Less Previous
Payments
Pay at this time
FUND
Municipal (MSAS > 5000)
$
-
$
-
Regular (CSAH)
$
-
$
-
Municipal (MSAH < 5000)
$
-
$
-
Town Bridge
$
-
$
-
Special Town Bridge
$
-
$
-
Turnback
$
-
$
-
State Park
$
-
$
-
State Aid Disaster
$
-
$
-
$
-
$
-
Local / Other
specify
Local / Other
specify
Federal
State Aid Bonds Applied
Credit for Local Effort
(attach abstract detailing items)
Check if Bond Eligible Items are 100% Complete.
BrBnd/Oth Bnd Prgms
(identify eligible items)
Acct#
Sub-Total
Other Costs
FUND
Total Grant Amount
$
Certified & Paid To Date
-
$
%
*Description
TOTAL
Total Oblig/Paid
$
Requested
-
-
$
Amount
Requested
Less Previous
Payments
Pay at this time
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
Remarks:
*Other Cost Description: Right-of-Way (ROW), Engineering (ENG)-Max 25%, Maintenance Facility (MF), Force Account (FA). FA includes work performed by
force labor such as work by local agencies, R/R, utility work, or contractors if not let under bids. Also agency furnished materials must include a FA
agreement.
I certify that: (a) Engineering & ROW costs requested above are a reimbursement for
costs incurred, or a percentage of estimated costs. (b) Wage rates specified in the
contract were paid and are equal or exceed the minimum hourly rates required for work
on state funded projects as determined by the MN Dept. of Labor and Industry. (c)
Inspection on the state-aid funded portions of this project were performed by
personnel certified in accordance with state-aid directives. (d) Work required by this
contract was completed in accordance with and pursuant to the terms of this contract.
(e) Payment and performance bonds for the full amount of the contract have been
provided with aggregate liability of the bond(s) to twice the full amount of the
contract.
/
Approved by: County/City Engineer
/
Date
I certify all costs are reasonable. For finals I accept all work performance as in
compliance with the approved plans and specifications. DSAE signature for
Maintenance Facilities is not required on this form; prior approval was received.
/
Approved by: District State Aid Engineer
/
Date
/
Approved by: State Aid Finance
/
Date
MN/DOT 30172 revised June 2013
Checking the Request
STATE AID PAYMENT REQUEST
County/City
Report: Partial
Bid Opening Date:
Local Proj. ID (opt)
Before you submit your payment request to the
DSAE check the following:
Sub-Total: This field will auto calculate and
MUST equal the awarded bid or the current
value of work certified.
Total: Again these will auto calculate. Any costs
in addition to the contract costs must have
documentation, and the total of the
documentation MUST equal the first column
total. The total amount requested should make
sense when you review your documentation.
Less previous payments must be equal to any
previously paid funds on this project. The total
to be paid at this time should be reasonable
and you should be able to calculate the same
number from your documentation.
Signatures: The payment request must be
signed and dated by the local agency’s
engineer. The DSAE will sign the pay request
before it is forwarded to the State Aid Finance
office. Payments will not be made if both
parties have not signed.
Final
Award Date:
Project Type: SP
SAP
Project #:
Tied Projects:
Bond Co.
Contractor:
Constr. Completed Date:
Funding below is for this project number only. Costs for projects or agreements tied to this project should not be
included on this request. A separate State Aid Payment Request must be submitted for each project number. Final reports must include
a final estimate detailing quantity, unit price and extension splits for each project number. Bridge eligible items must be identified on the abstract.
Project Funding:
Contract Costs (this SAP only)
Total Obligated
Costs
%
Amount
Requested
Requested
Less Previous
Payments
Pay at this time
FUND
Municipal (MSAS > 5000)
$
-
$
-
Regular (CSAH)
$
-
$
-
Municipal (MSAH < 5000)
$
-
$
-
Town Bridge
$
-
$
-
Special Town Bridge
$
-
$
-
Turnback
$
-
$
-
State Park
$
-
$
-
State Aid Disaster
$
-
$
-
$
-
$
-
Local / Other
specify
Local / Other
specify
Federal
State Aid Bonds Applied
Credit for Local Effort
(attach abstract detailing items)
Check if Bond Eligible Items are 100% Complete.
BrBnd/Oth Bnd Prgms
(identify eligible items)
Acct#
Sub-Total
Other Costs
FUND
Total Grant Amount
$
Certified & Paid To Date
-
$
%
*Description
TOTAL
Total Oblig/Paid
$
Requested
-
-
$
Amount
Requested
Less Previous
Payments
Pay at this time
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
Remarks:
*Other Cost Description: Right-of-Way (ROW), Engineering (ENG)-Max 25%, Maintenance Facility (MF), Force Account (FA). FA includes work performed by
force labor such as work by local agencies, R/R, utility work, or contractors if not let under bids. Also agency furnished materials must include a FA
agreement.
I certify that: (a) Engineering & ROW costs requested above are a reimbursement for
costs incurred, or a percentage of estimated costs. (b) Wage rates specified in the
contract were paid and are equal or exceed the minimum hourly rates required for work
on state funded projects as determined by the MN Dept. of Labor and Industry. (c)
Inspection on the state-aid funded portions of this project were performed by
personnel certified in accordance with state-aid directives. (d) Work required by this
contract was completed in accordance with and pursuant to the terms of this contract.
(e) Payment and performance bonds for the full amount of the contract have been
provided with aggregate liability of the bond(s) to twice the full amount of the
contract.
/
Approved by: County/City Engineer
/
Date
I certify all costs are reasonable. For finals I accept all work performance as in
compliance with the approved plans and specifications. DSAE signature for
Maintenance Facilities is not required on this form; prior approval was received.
/
Approved by: District State Aid Engineer
/
Date
/
Approved by: State Aid Finance
/
Date
QUESTIONS?