APPLICATION FOR PAYMENT |
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Number: |
1 | Period: |
Month | |||||||
Project Name: |
Construction | Owner: |
Myself | |||||||
Contractor: |
AA Builder | |||||||||
Address: |
47 Brick Ave | |||||||||
Project Number |
1045 | |||||||||
Facility: |
School | |||||||||
Contract Start Date |
1-1-11 | |||||||||
Application Date: |
may 2011 | |||||||||
Change Order Summary: |
Additions |
Deductions |
||||||||
Previous Change Orders |
$15,000 | $3000 | ||||||||
Total Change Orders |
$12000 | |||||||||
Change Orders Approved This Month |
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Number |
Date Approved |
|||||||||
| 12 | may 23,2011 | |||||||||
| 13 | may 30,2011 | |||||||||
Total |
$4,000 | |||||||||
Net Change By Change Orders |
$16,000 | |||||||||
Application is made for payment under the Contract as shown below: |
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1. ORIGINAL CONTRACT SUM |
$100,000 | |||||||||
2. NET CHANGE BY CHANGE ORDERS |
$16,000 | |||||||||
3. CONTRACT SUM TO DATE (Line 1 ± Line 2) |
$116,000 | |||||||||
4. TOTAL AMOUNT COMPLETED TO DATE (From Schedule 1) |
$0.00 | |||||||||
5. RETENTION: % of Completed Work (From Schedule 1) |
$0.00 | |||||||||
6. TOTAL EARNED LESS RETENTION (Line 4 less Line 5) |
$0.00 | |||||||||
7. TOTAL AMOUNT PREVIOUSLY PAID |
$0.00 | |||||||||
8. CURRENT PAYMENT DUE (Line 6 less Line 7) |
$0.00 | |||||||||
9. BALANCE TO FINISH, PLUS RETENTION (Line 3 less Line 6) |
$116,000 | |||||||||
The undersigned Contractor hereby represents and warrants to Owner that all Work,
for which Certificates For Payment have previously been issued and payment received from Owner,
is free and clear of all claims, stop notices, security interests, and encumbrances in favor of
Contractor, any Subcontractor, and any other persons or firms entitled to make claims by reason
of having provided labor, materials, or equipment related to the Work.
The following Schedules are attached and incorporated herein, and made a part of this Application For Payment:
Schedule 1 Cost Breakdown Schedule
Schedule 2 List of Subcontractors
Schedule 3 Declaration of Releases of Claims
__________________________________
(Contractor)
By:_____________________________
(Name)
________________________________
(Title)
DECLARATION
I,__________________________ , hereby declare that I am the ________________________________
of Contractor submitting this Application For Payment; that I am duly authorized to execute
and deliver this Application For Payment on behalf of Contractor; and that all information set
forth in this Application For Payment and all Schedules attached hereto are true, accurate,
and complete as of its date.
I declare, under penalty of perjury, that the foregoing is true and correct and that this
declaration was subscribed at
____________________,________________________ , State of_______________________________
On _____________________ , 20___
__________________________________
Signature
________________________________
Print Name