USUAL FORMS FOR CONTRACTOR'S INTERIMAR PAYMENT REQUESTS

IPR - Value of Works

Annex 1 - RETURN OF ADVANCE
Annex 2 - RETENTIONS
Annex 3 - ADDITIONAL AND DEDUCTABLE VALUES
Annex 4 - CERTIFIED VALUES FOR DELIVERY MACHINE AND EQUIPMENTS
Annex 5 - LIST OF VARIATIONS
Annex 6 - MEASUREMENT FORM
Annex 7 - LIST WITH QUANTITIES AND PRICES

SIL - Valoarea lucrarilor

Anexa 1 - RESTITUIREA AVANSULUI
Anexa 2 - RETINERI
Anexa 3 - SUME CE SE ADAUGA SAU DEDUCERI
Anexa 4 - VALOAREA CERTIFICATA PENTRU LIVRAREA UTILAJELOR SI ECHIPAMENTELOR
Anexa 5 - LISTA VARIATIILOR
Anexa 6 - MASURATORI
Anexa 7 - LISTE DE CANTITATI SI PRETURI
R SI ECHIPAMENTELOR
Contract : Autobaza S.C. Tursib S.A., inprejmuire, bramsamente utilitati
Beneficiar: S.C. TURSIB S.A.
Consultant: S.C. DAN CON S.R.L.
Antreprenor: Asocierea intre: S.C. CON-A S.R.L in calitate de lider & S.C. SINECON S.A.

VALOAREA CERTIFICATA A LUCRAILOR

CERTIFICAT INTERIMAR DE PLATA NR.

Cap/subcap/ nr Valoarea Lucrarilor

Valoarea Valoare revizuita
Nr. lista de cantitati/ Descrierea categoriilor de lucrari
contractata conform O.V. nr.1
obiect
anterior prezent
0 1 2 3 4 5 6
1 CAP. I Amenajarea terenului 48,063.54 48,063.54 0.00
3 I.2 1.2 Amenajarea terenulu 27,700.47 27,700.47 0.00
4 I.3 1.3 Amenajari pentru protectia mediului 20,363.07 20,363.07 0.00
CAP. II Cheltuieli cu utilitatile 569,699.78 569,699.78 0.00
5 II.1 2.11 Alimentare cu apa 74,432.56 74,432.56 0.00
6 II.2 2.12 Canalizare 192,077.65 192,077.65 0.00
7 II.3 2.13 Alimentare cu gaze naturale 4,452.60 4,452.60 0.00
8 II.4 2.15 Alimentare cu energie electrica 130,970.90 130,970.90 0.00
9 II.5 2.16 Alimentare cu energie electrica - curenti slabi 98,654.09 98,654.09 0.00
10 II.6 6.16 Utilitati 69,111.98 69,111.98 0.00
CHAPTER IV EXPENSES WITH INVESTMENT
IV.1 CONSTRUCTII SI INSTALLATII 3,309,530.04 3,299,573.55 0.00
11 411 Bussport 844,088.82 834,132.33 0.00
12 412 Statie de alimentare cu carburant 128,708.86 128,708.86 0.00
13 413 Statie de spalare 180,140.93 180,140.93 0.00
14 414 Stand de inspectie tehnica periodica ITP 190,034.61 190,034.61 0.00
15 415 Atelier intretinere 423,757.18 423,757.18 0.00
16 416 Cladire administrativa 1,030,079.20 1,030,079.20 0.00
17 4171 Drumuri de acces si platforme 437,712.16 437,712.16 0.00
18 4174 Imprejmuiri si porti 67,383.12 67,383.12 0.00

Page 3 of 24
 Cap/subcap/ nr
Valoarea Valoare revizuita Valoarea Lucrarilor
Nr. lista de cantitati/ Descrierea categoriilor de lucrari
contractata conform O.V. nr.1
obiect
anterior prezent
0 1 2 3 4 5 6
19 4175 Cabina poarta 7,625.16 7,625.16 0.00
IV.2 MONTAJ UTILAJE SI ECHIPAMENTE TEHNOLOGICE 129,856.11 129,856.11 0.00
20 411 Instalatii electrice interioare Bussport 39,188.02 39,188.02 0.00
21 412 Instalatii electrice interioare statie de carburant 21,648.22 21,648.22 0.00

22 413 Instalatii electrice interioare statie de spalare 9,715.00 9,715.00 0.00

23 414 Instalatii electrice interioare ITP 11,033.37 11,033.37 0.00
24 415 Instalatii electrice interioare atelier de intretinere 47,858.24 47,858.24 0.00

25 416 Instalatii electrice interioare cladire administrativa 413.26 413.26 0.00

ACHIZITIA DE UTILAJE SI ECHIPAMENTE
IV.3 520,153.86 520,153.86 0.00
TEHNOLOGICE
26 411 Bussport 5,049.66 5,049.66 0.00
27 412 Statie de alimentare cu carburant 1,937.75 1,937.75 0.00
28 413 Statie de spalare 1,970.79 1,970.79 0.00
29 414 Stand de inspectie tehnica periodica ITP 4,182.47 4,182.47 0.00
30 415 Atelier intretinere 12,466.74 12,466.74 0.00
31 416 Cladire administrativa 494,546.45 494,546.45 0.00
CAP V ORGANIZARE DE SANTIER 18,417.64 22,187.52 0.00
32 5.1 Organizare de santier 18,417.64 22,187.52 0.00
TOTAL GENERAL al Lucrarilor (fara TVA) 4,595,720.97 4,589,534.36 0.00 0.00

Avans restituit 459,572.10 0.00 0.00

Retineri (10% din valoarea de contract) 459,572.10 0.00 0.00

Deduceri 0.00 0.00

Utilaje si echipamente tehnologice 80% 0.00 0.00

Page 4 of 24
 Cap/subcap/ nr
Valoarea Valoare revizuita Valoarea Lucrarilor
Nr. lista de cantitati/ Descrierea categoriilor de lucrari
contractata conform O.V. nr.1
obiect
anterior prezent
0 1 2 3 4 5 6

TOTAL DE PLATA (fara TVA) 0.00 0.00

Reprezentant Antreprenor: . Date:

Page 5 of 24
 Proiect ID: 7251-GPN-37026

Valoarea lucrarilor

Perioada de raportare: ..
Data curenta:

ucrarilor Progres procentual

cumulat anterior prezent cumulat

7 8 9 10
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%

0.00 0.00% 0.00% 0.00%

0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%

Page 6 of 24
ucrarilor Progres procentual

cumulat anterior prezent cumulat

7 8 9 10
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%

0.00 0.00% 0.00% 0.00%

0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%

0.00 0.00% 0.00% 0.00%

0.00 0.00% 0.00% 0.00%

0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%
0.00 0.00% 0.00% 0.00%

0.00 0.00% 0.00% 0.00%

0.00 0.00% 0.00% 0.00%

0.00 0.00% 0.00% 0.00%

0.00 0.00% 0.00% 0.00%

Page 7 of 24
ucrarilor Progres procentual

cumulat anterior prezent cumulat

7 8 9 10

0.00

Page 8 of 24
Contract : Autobaza S.C. Tursib S.A., inprejmuire, bramsamente utilitati
Beneficiar: S.C. TURSIB S.A.
Consultant: S.C. DAN CON S.R.L.
Antreprenor: Asocierea intre: S.C. CON-A S.R.L in calitate de lider & S.C. SINECON S.A.
Perioada de raportare
Data curenta:
RESTITUIREA AVANSULUI
CERTIFICAT INTERIMAR DE PLATA

Valoare Contractata 4,595,720.97 Euro

Valoare maxima avans conform Anexa la Oferta 459,572.10 Euro

Pos. Perioada de raportare CIP nr. Valoare lucrari Plati Avans conform Anexa la Contract pct. 14.2
anterior prezent
1 1 0.00 0.00 0.00

TOTAL 0.00 0.00 0.00

Reprezentant Antreprenor: . Date:

Page 9 of 24
 Project ID: 7251-GPN-37026

Perioada de raportare: ..
..

Plati Avans conform Anexa la Contract pct. 14.2

cumulat
0.00

0.00

Page 10 of 24
Contract : Autobaza S.C. Tursib S.A., inprejmuire, bramsamente utilitati
Beneficiar: S.C. TURSIB S.A.
Consultant: S.C. DAN CON S.R.L.
Antreprenor: Asocierea intre: S.C. CON-A S.R.L in calitate de lider & S.C. SINECON S.A.
Perioada de raportare: ..
Data curenta:
RETINERI
CERTIFICAT INTERIMAR DE PLATA

Valoare Contractata 4,595,720.97 Euro

Valoare maxima retineri conform Anexa la Oferta 459,572.10 Euro

Pos. Perioada de raportare CIP nr. Valoare lucrari Retineri conform Anexa la Contract pct. 14.3
anterior prezent
1 1 0.00 0.00 0.00

TOTAL 0.00 0.00 0.00

Reprezentant Antreprenor: . Date:

 Project ID: 7251-GPN-
37026

Perioada de raportare: ..

Contract pct. 14.3

cumulat
0.00

0.00
Contract : Autobaza S.C. Tursib S.A., inprejmuire, bramsamente utilitati
Beneficiar: S.C. TURSIB S.A.
Consultant: S.C. DAN CON S.R.L.
Antreprenor: Asocierea intre: S.C. CON-A S.R.L in calitate de lider & S.C. SINECON S.A.

SUME CE SE ADAUGA SAU DEDUCERI

CERTIFICAT INTERIMAR DE PLATA 1

Descrierea categoriilor de lucrari/ descrierea Valoare certificata plata (dupa

Valoare contractata (euro)
echipamentelor
anterior (euro)
2 3 4
- - 0.00

Reprezentant Antreprenor: Date:

 Project ID: 7251-GPN-37026

ANNEX 3
S.C. CON-A S.R.L in calitate de lider & S.C. SINECON S.A.
Perioada de raportare: ..
Data curenta:

Valoare certificata plata (dupa retineri)

prezent (euro) cumulat (euro)

5 6
0.00 0.00

..
Contract : Autobaza S.C. Tursib S.A., inprejmuire, bramsamente utilitati
Beneficiar: S.C. TURSIB S.A.
Consultant: S.C. DAN CON S.R.L.
Antreprenor: Asocierea intre: S.C. CON-A S.R.L in calitate de lider & S.C. SINECON S.A.

VALOAREA CERTIFICATA PENTRU LIVRAREA UTILAJELOR SI ECHIPAMENTELOR

CERTIFICAT INTERIMAR DE PLATA 0

Descrierea categoriilor de lucrari/ descrierea Valoare certificata pentru echipamente

Valoare contractata (euro)
echipamentelor
anterior (euro)
2 3 4
- - 0.00

Reprezentant Antreprenor: Date:

 Project ID: 7251-GPN-37026

ANNEX 4
SINECON S.A.
Perioada de raportare: ..
Data curenta:

Valoare certificata pentru echipamente

prezent (euro) cumulat (euro)

5 6
0.00 0.00

.
Contract : Autobaza S.C. Tursib S.A., inprejmuire, bramsamente utilitati
Beneficiar: S.C. TURSIB S.A.
Consultant: S.C. DAN CON S.R.L.
Antreprenor: Asocierea intre: S.C. CON-A S.R.L in calitate de lider & S.C. SINECON S.A.

Data curenta:
LISTA VARIATIILOR
CERTIFICAT INTERIMAR DE PLATA 0

Valoare certificata plata

Descrierea VARIATIILOR O.V. nr.1 contractat valoare
anterior (euro) prezent (euro)
2 3 4 5
0 0.00

Reprezentant Antreprenor: .. Date: ..

Page 17 of 24
 Project ID: 7251-GPN-37026

ANNEX 5

Perioada de raportare: ..
.

Valoare certificata plata

cumulat (euro)
6
0.00

Page 18 of 24
Contract : CONSTRUCTION OF A NEW BUS DEPOT FOR S.C. TURSIB S.A.
Beneficiary: S.C. TURSIB S.A.
Consultant: S.C. DAN CON S.R.L.
Antreprenor: Joint venture between: S.C. CON-A S.R.L as lider & S.C. SINECON S.A.

Measurements
Object: 411 Busport
List: 01 Infrastructura modificata conform dispozitie de santier nr.3

Pos. Item Description of activity

SAPATURA MECANICA CU EXCAVATOR PE PNEURI DE 0.21-0.39 MC,CU

1 TSC02B1 HIDRAULICA,IN :...PAMANT CU UMIDITATE NATURALA DESCARCARE IN
TEREN CATG 1

calcule

Signatures list
On Site Supervisor Name/ signature

Contractor representative Name/ signature

 Project ID: 7251-GPN-37026

ANNEX 6

.
Current date: .

Contracted Q-ty .
MU Realised Q-ty .
Progress % .

PNEURI DE 0.21-0.39 MC,CU COMANDA Contracted Q-ty 0

NATURALA DESCARCARE IN DEPOZIT 100 mc Realised Q-ty 0
Progress % #DIV/0!

Stamp

Stamp
Contract : Autobaza S.C. Tursib S.A., inprejmuire, bramsamente utilitati
Beneficiar: S.C. TURSIB S.A.
Consultant: S.C. DAN CON S.R.L.
Antreprenor: Asocierea intre: S.C. CON-A S.R.L in calitate de lider & S.C. SINECON S.A.

LISTA DE CANTITATI SI PRETURI

Ob. 411 Busport
List: 01 Infrastructura modificata conform dispozitie de santier nr.3

COSTURI CONTRACTATE cf O.M. COSTURI ANTERIOARE

Pret unitar Valoare Cantitate
Total Total
Material Material
Cantitate
Nr. Simbol Descrierea activitatii UM Manopera Manopera
contractata
Utilaj Utilaj
Transport Transport
SECTIUNEA TECHNICA SECTIUNEA FINANC
0 1 2 3 4 5 6
1 TSC02B1 SAPATURA MECANICA CU EXCAVATOR PE PNEURI 100 mc 36.62000 133.28 4,880.75 0.00
DE 0.21-0.39 MC,CU COMANDA HIDRAULICA,IN
:...PAMANT CU UMIDITATE NATURALA DESCARCARE 0.00 0.00
IN DEPOZIT TEREN CATG 1 0.00 0.00
133.28 4,880.75
0.00 0.00
Material
Manopera
Utilaj
Transport
TOTAL I
CAS 15.80%
Fond de risc 0.27%
Concedii si indemnizatii 0.85%
 Somaj 0.50%
Fond de garantare 0.25%
Sanatate 5.20%
TOTAL II
Cheltuieli indirecte 3.25%
Profit 2.00%
TOTAL euro fara TVA

Lista semnaturi:

Reprezentant Antreprenor: .
 Project ID: 7251-GPN-37026

ANNEX 7

Perioada de raportare: ..
Data curenta: .

COSTURI ANTERIOARE COSTURI CURENTE COSTURI CUMULATE

Valoare Cantitate Valoare Cantitate Valoare
Total Total Total
Material Material Material
Manopera Manopera Manopera
Utilaj Utilaj Utilaj
Transport Transport Transport
SECTIUNEA FINANCIARA
7 8 9 10 11
0.00 0.00 0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00 0.00 0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00