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APPLICATION FOR PAYMENT NO. <br />To: <br />From: _ <br />Contract: <br />(OWNER) <br />(CONTRACTOR) <br />Project: <br />OWNER's Contract No. ENGINEER's Project No. <br />For Work accomplished through the date of: <br />1. Original Contract Price: <br />2. Net change by Change Orders and Written Amendments (+ or <br />3. Current Contract Price (1 plus 2): <br />4. Total completed and stored to date <br />5. Retainage (per Agreement): <br />% of completed Work: $ <br />% of stored material: $ <br />il <br />Total Retainage: $ <br />6. Total completed and stored to date less retainage (4 minus 5): $ <br />7. Less previous Application for Payments: $ <br />8. DUE THIS APPLICATION (6 MINUS 7): $ <br />Accompanying Documentation: <br />CONTRACTOR'S Certification: <br />The undersigned CONTRACTOR certifies that (1) all previous progress payments received from OWNER on account <br />of Work done under the Contract referred to above have been applied on account to discharge CONTRACTOR's <br />legitimate obligations incurred in connection with Work covered by prior Applications for Payment numbered 1 <br />through inclusive; (2) title of all Work, materials and equipment incorporated in said Work or otherwise listed <br />in or covered by this Application for Payment will pass to OWNER at time of payment free and clear of all Liens, <br />security interests and encumbrances; (3) all Work covered by this Application for Payment is in accordance with the <br />Contract Documents and not defective; and (4) I hereby certify that the labor and materials listed on this <br />Application for Payment have been used in the construction of this Work and payment received from the <br />last request for payment has been used to make payments to all subcontractors, laborers, material, men and <br />suppliers except as listed below: " <br />Dated <br />By: <br />State of <br />County of <br />Subscribed and sworn to before me this <br />day of , <br />Notary Public <br />My Commission expires: <br />Payment of the above AMOUNT DUE THIS APPLICATION is recommended. <br />Dated <br />CONTRACTOR <br />ENGINEER <br />By: <br />EJCDC No. C -700-E (2002 Edition) <br />Prepared by the Engineers Joint Contract Documents Cont nitree and endorsed by The Associated General Contractors of America and the Construction Specification Institute. <br />044572017 <br />00800-26 <br />