Orange County NC Website
Browse       Search
DocuSign Envelope ID:07A4359F-6D47-4987-B1F1-BF667ACBB3BA <br /> Contractor's Application For Payment No. <br /> Application Period: Application Date: <br /> To(Owner): From(Contractor): Via(Engineer) <br /> Project: Contract: <br /> Owner's Contract No.: Contractor's Project No.: Engineer's Project No.: <br /> APPLICATION FOR PAYMENT <br /> Change Order Summary <br /> Approved Change Orders 1. ORIGINAL CONTRACT PRICE.......................................................... $ <br /> Number Additions Deductions 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 on Progress Estimate) ................................................... $ <br /> 5. RETAINAGE: <br /> a. %x$ Work Completed..................... $ <br /> b. %x$ Stored Material....................... $ <br /> c. Total Retainage(Line 5a+Line 5b) ............................................ $ <br /> 6. AMOUNT ELIGIBLE TO DATE(Line 4-Line 5c).............................. $ <br /> TOTALS 7. LESS PREVIOUS PAYMENTS(Line 6 from prior Application)....... $ <br /> 8. AMOUNT DUE THIS APPLICATION.................................................. $ <br /> NET CHANGE BY 9. BALANCE TO FINISH,PLUS RETAINAGE <br /> CHANGE ORDERS <br /> (Column G on Progress Estimate+Line 5 above).......................... $ <br /> CONTRACTOR'S CERTIFICATION <br /> The undersigned Contractor certifies that: (1)all previous progress payments received Payment of: $ <br /> from Owner on account of Work done under the Contract have been applied on (Line 8 or other-attach explanation of other amount) <br /> account to discharge Contractor's legitimate obligations incurred in connection with <br /> Work covered by prior Applications for Payment; (2) title of all Work, materials and <br /> equipment incorporated in said Work or otherwise listed in or covered by this is recommended by: <br /> Application for Payment will pass to Owner at time of payment free and clear of all (Engineer) (Date) <br /> Liens, security interests and encumbrances (except such as are covered by a Bond <br /> acceptable to Owner indemnifying Owner against any such Liens, security interest or Payment of: $ <br /> encumbrances); and (3) all Work covered by this Application for Payment is in (Line 8 or other-attach explanation of other amount) <br /> accordance with the Contract Documents and is not defective. <br /> is approved by: <br /> (Owner) (Date) <br /> By: Date: Approved by: <br /> Funding Agency(if applicable) (Date) <br /> EJCDC No.C-620(2002 Edition) Page 1 of 3 <br /> Prepared by the Engineers'Joint Contract Documents Committee and endorsed by the Associated General Contractors of America and the Construction Specifications Institute. <br />