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Contractor's Application for Payment No. <br />Application Application Date: <br />Period: <br />To From (Contractor): Via (Engineer): <br />(Owner): <br />Project: Contract: <br />Owner's Contract No.: Contractor's Project No.: <br />Engineer's Project No.: <br />1. ORIGINAL CONTRACT PRICE...........................................................................$ <br />2. Net change by Change Orders......................................................................................$ <br />3. Current Contract Price (Line 1 ± 2)................................................................................................$ <br />4. TOTAL COMPLETED AND STORED TO DATE <br /> (Column F total on Progress Estimates).............................................................................................................$ <br />5. RETAINAGE: <br />a. X Work Completed..............................................$ <br />b. X Stored Material..............................................$ <br />c.Total Retainage (Line 5.a + Line 5.b).........................................................................................................................................$ <br />6. AMOUNT ELIGIBLE TO DATE (Line 4 - Line 5.c)....................................................................................................................$ <br />7. LESS PREVIOUS PAYMENTS (Line 6 from prior Application).........................................................................................................$ <br />8. AMOUNT DUE THIS APPLICATION....................................................................................................................................$ <br />9. BALANCE TO FINISH, PLUS RETAINAGE <br /> (Column G total on Progress Estimates + Line 5.c above).....................................................................................................$ <br />Contractor's Certification <br /> Payment of: $ <br /> is recommended by: <br /> Payment of: $ <br /> is approved by: <br />Contractor Signature <br />By: Date: Approved by: <br />CHANGE ORDERS <br />(Date) <br />(Date)(Engineer) <br />(Owner) <br />(Line 8 or other - attach explanation of the other amount) <br />(Line 8 or other - attach explanation of the other amount) <br />(Date) <br />Funding or Financing Entity (if applicable) <br />NET CHANGE BY <br />TOTALS <br />Application For Payment <br />Change Order Summary <br />Number DeductionsAdditions <br />Approved Change Orders <br />The undersigned Contractor certifies, to the best of its knowledge, the following: <br />(1) All previous progress payments received from Owner on account of Work done under the Contract <br />have been applied on account to discharge Contractor's legitimate obligations incurred in connection with <br />the Work covered by prior Applications for Payment; <br />(2) Title to all Work, materials and equipment incorporated in said Work, or otherwise listed in or <br />covered by this Application for Payment, will pass to Owner at time of payment free and clear of all <br />Liens, security interests, and encumbrances (except such as are covered by a bond acceptable to Owner <br />indemnifying Owner against any such Liens, security interest, or encumbrances); and <br />(3) All the Work covered by this Application for Payment is in accordance with the Contract Documents <br />and is not defective. <br />EJCDC® C-620 Contractor's Application for Payment <br />© 2013 National Society of Professional Engineers for EJCDC. All rights reserved. <br />Page 1 of 1 <br />DocuSign Envelope ID: BBF56E0A-3618-497E-AA70-92F097E8F598