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4D <br />APPLICATION COIL PAYMENT NO. <br />To— <br />Contract <br />a Contract for <br />OWNER's Project No. ENGINUR's Project No. <br />For Work accomplished through the bate of — <br />Accompanying Documentatfort: GROSS AMOUNT DUE ....................... S <br />LESS —% RETAINAGE ................... $— <br />A MO U NT <br />- <br />AMOUNT DUE TO DATE ..................... S <br />LESS PREVIOUS PAYMENTS ................ S <br />AMOUNT DUE THIS APPLICATION ......... S <br />CONTRACTOR'S Certification: <br />The undcrsigacd CONTRACTOR certifies that [1] all previous progress payments received from OWNER on account of <br />Work done under the Contract referred to above have been applied to discharge in full all obligations of CONTRACTOR <br />incurred in connection with Work covered by prior Applications for Payment numbered I through -Inclusive; and <br />(i) title to aU materials and equipment incorporated in said Work or otherwise listed in or covercd by this Application for <br />Payment will pass to OWNER at time of payment free acid clear of all liens, claims, security interests and encumbrances <br />(except s%ich as covered by Bond acceptable to OWNER): <br />Dated 19 - cOMTRAL70 <br />By <br />Payment of the above AMOUNT' DUE THIS APPLICATION is recommcndcd. <br />Dated --• 19 <br />lly <br />