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!r <br /> Exhibit B <br /> Illinois Department Engineering Payment Report <br /> of Transportation <br /> Prime Consultant <br /> Name <br /> Address <br /> Telephone <br /> TIN Number <br /> Project Information <br /> Local Agency <br /> Section Number <br /> Project Number <br /> Job Number <br /> This form is to verify the amount paid to the Sub-consultant on the above captioned contract. Under penalty of law for <br /> perjury or falsification, the undersigned certifies that work was executed by the Sub-consultant for the amount listed below. <br /> Sub-Consultant Name TIN Number Actual Payment <br /> from Prime <br /> Sub-Consultant Total: <br /> Prime Consultant Total: <br /> Total for all Work <br /> Completed: <br /> Signature and title of Prime Consultant Date <br /> Note: The Department of Transportation is requesting disclosure of information that is necessary to accomplish the <br /> statutory purpose as outlined under state and federal law. Disclosure of this information is REQUIRED and shall be <br /> deemed as concurring with the payment amount specified above. <br /> For information about IDOTs collection and use of confidential information review the department's Identity Protection Policy. <br /> Page 8 of 8 BLR 05613(Rev. 11/21/13) <br /> Printed on 2/7/2017 5:15:50 PM <br /> J-9 <br />