Budget No.
2-C ContractsTask/Job No.
Application/Certificate of PaymentRef. No.
Code No.
Project No.
PO No.
CAMPUS:Select Campus LocationAPPLICATION DATE:
BUILDING NAME:PAYMENT NO.:
PROJECT:CONTRACT DATE:
Final PaymentYesNo
ARCHITECT:Steel Certificate Forms YesNo
Original Contract$
Change Orders to Date — Additions$
Change Orders to Date — Deductions$
Change Orders to Date — Net$0.00
TOTAL CONTRACT AND CHANGE ORDERS THIS DATE$0.00
This is to certify that
is entitled to the amount of
Dollars
and hereby certifies, to the best of the undersigned's knowledge and belief, that:
(1) The amount requested is only for performance in accordance with the specifications, terms, and conditions of the contract;
(2) Payments to subcontractors and suppliers have been made from previous payments received under the contract, and timely payments will be made from the proceeds of the payment covered by this certification, in accordance with subcontract agreements;
(3) This request for progress payments does not include any amounts which the prime contractor intends to withhold or retain from a subcontractor or supplier in accordance with the terms and conditions of the subcontract.
Total Value of Work Done Previous Application
Value of Work Done This Month
Total Value of Work Done to Date This Application$ -
Less Retained Reserve@0%$ -
Total Value of Work Done to Date Less Reserve$ -
Less Previous Payments
TOTAL AMOUNT DUE CONTRACTOR THIS DATE*$ -
CERTIFIED BY:RECOMMENDED BY:
ContractorDateArchitect/EngineerDate
Note: For every payment, please provide a Steel Certificate. For final payments, please provide Certified Payroll, Steel Certificate, Contractors Affidavit for Final Payment, Waiver of Mechanics Lien, OSHA recordable accident data and Construction waste management documentation.
Physical Plant RepresentativeDate
Commonwealth of PA Payroll Certification Notice.pdf
No Work Report.pdf
Steel Certification Form.pdfContractors Affidavit for Final Payment.pdfWaiver of Mechanics Lien.pdfrev bmo 5/11/16