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FORM OF PAYMENT APPLICATION
55
XPPLICA
.O (OWNER):
ON AND CERTIFICATE FOR PAYMENT A!A DOCUMENT C702
PROJECT:
ROM (CONTRACTOR):
:ONTRACT F01
VIA (ARCHITECT):
2ONTRAtTOR'S APPLICATION FOR PAYMENT
CHANCE °RDA SUMMARY
Change OrderAlpproved in
previous montta by Owner
TOTAL
Approved this
Number
ADDITIONS
DEDUCTIONS
nth
De Approved
41.
TO1ALS
Net change by aange Orders
he undersigned ontractor certifies that to the best of the Contractor's knowledge,
'formation and lief the Work covered by this Application for Payment has been
-tmpleted in ace dance with the Contract Documents, that all amounts have been
aid by the ConlActor for Work for which previous Certificates for Payment were
sued and paymr lets received from the Owner, and that current payment shown
rrein is now dut1e
ONTRACTO R:
L
Date:
►RCHITEth'S CERTIFICATE FOR PAYMENT
(Instructions on reverse side)
APPLICATION NO:
PERIOD TO:
ARCHITECTS
PROJECT NO:
CONTRACT DATE:
F:al:! urit t. F I'\GI S
Distribution tto:
L.I OWNER
C_) AI; C't 1 l I E C" 1
l_3 CUNT KAOOK
n
("]
Application is made for Payment, as shown below, in connection with th • Con tr.ic t.
Continuation Sheet, AIA Document C703, is attached.
1. ORIGINAL CONTRACT SUM
2. Net change by Change Orders
3. CONTRACT SUM TO DATE (Line 1 + 2)
4. TOTAL COMPLETED & STORED TO DATE
(Column G on G703)
5. RETAINAGE:
a ` % of Completed Work $
(Column D -t~ E on G703) "
b ` % of Stored Material S
(Column F on G703)
Total Retainage (Line 5a + 5b or
Total in Column I of G703) S
6. TOTAL EARNED LESS RETAINAGE - S
(Line 4 less Line 5 Total)
7. LESS PREVIOUS CERTIFICATES FOR
PAYMENT (Line 6 from prior Certificate)
8. CURRENT PAYMENT DUE S
9. BALANCE TO FINISH, PLUS RETAINAGE $
(Line 3 less Line 6)
State of: County of:
Subscribed and sworn to before me this clay of .19
Notary Public:
My Commission expires:
i accordance wit the Ccmtract Documents, based on on -site observations and the
ata comprising II above application, the Architect certifies to the Owner that to the
2,1 of ttw Aril nu! is knowledge, information and belief the Work has progressed as
dicated, the qua y of the Work is in accordance with the Contract Documents, and
e Contractor is tittitled to payment of the AMOUNT CERTIFIEn
A DOCUMINT C702LAI'ptIC:ATION AND i_ktnIFlc 1[ FOR PAYMENT • MAY 1%3 11)1 ION • AM • 7n 19113
11 AMERICAN INSII lk OF ARCH11Tc;TS. 1715 NEW YORK AVENUF. N.W WASHINGTON. D.C. 2t(Ei,
AMOUNT CERTIFIED - 5
(Attach explanation if amount certified differs from the amount lffltfted (Lit.)
ARCI111 ECT:
By: Dale:
This Certificate is not negotiable, . t'---
n--..---.�. The r.tvtvurrt C..tICT)r1Yf] is payable only to• the
Contractor named herein. Issuance. payment anrt
Ij rt'itiriirn tr, �..., 1�.�
.- - •o • n rights of the Owner or Contractor tuidir this Contract.
x LI Iz X2
-L70'1-10119
:ONTINI%ATION SHEET
IA Document C7
ontractor's signs
tabulations Melt
se Column I on
A
'TEM
NO.
APPLICATION AND CERTIFICATE FOR PAYMENT, containing
Certification is attached.
amounts are stated to the nearest dollar.
ontracts where variable retainage for line c items may apply.
R
DESIPTION OF WORK
SCHEDULED
VALUE
D
A!A DOCUMENT G703 (instructions on reverse side) l:u:t OI PAU1
E
WORK COMPLETED
FROM PREVIOUS
APPLICATION
(D+E)
THIS PERIOD
APPLICATION NUMBER:
APPLICATION DAF[:
PERIOD TO:
ARCHITECT'S PROJECT NO:
F
MATERIALS
PRESENTLY
STORED
(NOT IN
DORE)
G
TOTAL
COMPLETED
AND STORED
TO DATE
ID+E+FI
w
ICI' CI
BALANCE
TO FINIS!'
IC-G1
RE !AINA(:l
IA DOCUMENT G7 APPLICATION AND CERTIFICATE FOR PAYMENT • MAY 1983 EDITION • AIA• • ID1903
It AMERI(AN 1NS11 1E OF ARCHITECTS, 1735 NEW YORK AVENUE. N.W., WASHINGTON. D.C. 20006
C7tl_I- i nRa