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Contractor's Application for Payment No.Application Application Date:Period:To From (Contractor): Via (Engineer):(Owner):Project: Contract:Owner's Contract No.: Contractor's Project No.:Engineer's Project No.:1. ORIGINAL CONTRACT PRICE...........................................................................$2. Net change by Change Orders......................................................................................$3. Current Contract Price (Line 1 ± 2)................................................................................................$4. TOTAL COMPLETED AND STORED TO DATE (Column F total on Progress Estimates).............................................................................................................$5. RETAINAGE:a. XWork Completed..............................................$b. XStored Material..............................................$c.Total Retainage (Line 5.a + Line 5.b).........................................................................................................................................$6. AMOUNT ELIGIBLE TO DATE (Line 4 - Line 5.c)....................................................................................................................$7. LESS PREVIOUS PAYMENTS (Line 6 from prior Application).........................................................................................................$8. AMOUNT DUE THIS APPLICATION....................................................................................................................................$9. BALANCE TO FINISH, PLUS RETAINAGE (Column G total on Progress Estimates + Line 5.c above).....................................................................................................$Contractor's Certification Payment of: $ is recommended by: Payment of: $ is approved by:Contractor SignatureBy: Date: Approved by:CHANGE ORDERS(Date)(Date)(Engineer)(Owner)(Line 8 or other - attach explanation of the other amount)(Line 8 or other - attach explanation of the other amount)(Date)Funding or Financing Entity (if applicable)NET CHANGE BYTOTALSApplication For PaymentChange Order SummaryNumber DeductionsAdditionsApproved Change OrdersThe undersigned Contractor certifies, to the best of its knowledge, the following:(1) All previous progress payments received from Owner on account of Work done under the Contract have been applied on account to discharge Contractor's legitimate obligations incurred in connection with the Work covered by prior Applications for Payment;(2) Title to all Work, materials and equipment incorporated in said Work, or otherwise listed in or covered by this Application for Payment, will pass to Owner at time of payment free and clear of all Liens, security interests, and encumbrances (except such as are covered by a bond acceptable to Owner indemnifying Owner against any such Liens, security interest, or encumbrances); and(3) All the Work covered by this Application for Payment is in accordance with the Contract Documents and is not defective.EJCDC® C-620 Contractor's Application for Payment© 2013 National Society of Professional Engineers for EJCDC. All rights reserved.Page 1 of 1Docusign Envelope ID: 34F94CE0-2CE8-49C5-B7C4-6B696F8E23C3