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EXHIBIT H
FORM OF PAYMENT APPLICATION
55
kPPLICA N AND CERTIFICATE FOR PAY
D (OWNER): MENT AMDOCUMENT C702
PROJECT:
(OM (CONTRACJit):
VIA (ARCHITECT):
DNTRACT FOR:
:ONTRACIOR'S APPLICATION FOR
:HANI R SUMMARY PAYMENT
:hinge Orders a roved in
irevielus months Owner ADDITIONS DEDUCTIONS
TOTAL.
•pproved this Mc) th
lumber Date.! Approved
10
IAI-S
et chanie by Ch&hge Orders
undersigned Co tractor certifies that to the best of the Contractor's knowledge,
)rmation and belltf the Work covered by this Application for Payment has
ipleted in accor nce with the Contract Documents, that all amounts have been
I by the Contrac' r for Work for which previous Certificates for Payment were
ed and payment received from the Owner, and that current payment shown
,...in is now due.
slTRACTOR-
Date:
:CHITECTiS CERTIFICATE FOR PAYMENT
cot -dance wittt rl
comprising the a
of die Architect's
'ated, the duality
:Unlractor is enti
OCUMfNT G702 • At
.MERII:AN IN,IiIUlt
Coition 1 Documents, Rased on on -site observations and the
t)ve application, the Architect certifies to the Owner that to the
tiowled);e, information and belief the Work has progressed as
the Work is in accordance with the Contract Documents, and
.d to payment of die AMOUNT CERTiflra
ir'ATION ANT) d.ER1 r►lcrlr FOR PAYMENT • MAY 191E3 FUITION • A1A- • r4+ 1983
F ARc-ir11ICIS, 1715 NEW YORK-AVENUF• N.W.• WA'FiINC1c)N. A.C. Irnw.
(Instructions on reverse air(,.)
APPLICATION NO:
PERIOD TO:
ARCHITECT'S
PROJECT NO:
l)i%tl illtttic}n
I- I OWNER
1:1AK:1111(C-'t
E.J Ct)N'IRAC.10K
F-i
CONTRACT DATE:
Application is made for Payment, as shown below. in Cdlnnettion.titll t 1 ('t,i�t�.ict
Continuation Sheet, AIA Document C703, is attached.
1. ORIGINAL CONTRACT SUM .......................
2. Net chin e h
$ y 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 b
(Column D + E on G703)
b % of Stored Material $
(Column F on G703)
Total Retainage (Line 5a + 5b or
Total in Column 1 of C703) ..... . . .:. . . .
6. TOTAL EARNED LESS RFTAINAGE .... _ , , _ •
(Line 4 less Line 5 Total)
7. LESS PREVIOUS CERTIFICATES FOR
8. CURRENT PAYMENT DUE
PAYMENT (Line 6 from prior Certificate) $ _y�
-
9. BALANCE TO FINISH, PLUS RETA!NAGE S
(Line 3 less Line 6) ti
State of:
Subscribed and sworn to before me thisCaunty of:
Notary Public:
My Commission expires:
AMOUNT CERTIFIED
(Attach explanation if arnount certified tldfe�rs from the .itt c)ttn1 .I!)llln•tl fen)
ARCHIT ECT:
day of . tv
By:
This Certificate is not .catnot negotiable. The AMC)UNI (:LR-IIFIi-n ,~,_1
ContractornamH¢here:rl cot ).ly nnllr 1I 1lL.•
issuance_ payment and
p,iudice co any rights of. the Owner or Contractor tinder this payment
art. �� ithout
t.
H ZIgIlX3
(:1)1 f9Q9
DNTINU = ION SHEET
.Document C702APPLICATION AND CERTIFICATE FOR PAYMENT, containing
flrattor's signed Etrtification is attached.
abulatinns hetoWl bmounts are stated to the nearest dollar.
Cnlumn I on Cc$4tracts where variable retainage for line items may apply.
tt
DLSCRIION OF WORK
SCHEDULED
VALUE
AIA DOCUMENT G703 (instructions on reverse side) (si
APPLICATION NUMBFR:
APPLICATION DATE:
PERIOD TO;
ARCHITECT'S PROJECT NO:
E
WORK COMPLETED
FROM PREVIOUS THIS PERIOD
APPLICATION
(U + El
YuC-CimENT, AND COMER -Jar tOR r'AYMrNT • MAY 1%I.n 3 1TION • AIA' • t+ 1983
AMERILAN INSIIIU ,bF ARCHITECTS, 1735 NM/ YORK AVENUE, N.W. WASHINGION. D.C. 20006
F
MATERIALS
PRESENTLY
STORED
(NOT IN
DOREl
G
TOTAL
COMPLETED
AND STORED
TO DATE
(DtEtF)
II
"• BALANCE kl 1AINA(:L -
(G C} 10 I INISH
(C-(:)