1-Application for Payment Fillable.pdf

283 KB Posted

Attached to
Tree and Brush Thinning- 14 Projects
Solicitation number
SB-FP-04-2526
Issued by
Kane County, Illinois

About this file

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This document is an Application for Payment Form from Kane County Forest Preserve District, located in Geneva, Illinois, celebrating its 100-year anniversary (1925-2025). The form is a standardized template designed for contractors to request payment for work completed on a project, with space to detail the contract value, work percentage, materials stored, retained amounts, and net amounts due. The form includes columns for tracking adjusted contract totals, work completed, retained amounts, previously paid funds, and balances becoming due.

The payment application provides a comprehensive financial tracking mechanism with sections for documenting the original contract amount, extras, total contract value, credits, and net amounts. The form requires a sworn statement from the contractor and allows for multiple change orders to be recorded. Contact information for the Kane County Forest Preserve District is provided, including their address at 1996 South Kirk Road, Suite 320, Geneva, Illinois 60134, with phone and fax numbers, and web address (www.kaneforest.com). The organization's leadership is noted as Bill Lenert (President) and Benjamin Haberthur (Executive Director), and their mission statement emphasizes preserving and restoring the nature of Kane County.

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To preserve and restore the nature of Kane County

1996 South Kirk Road, Suite 320, Geneva, Illinois 60134

Bill Lenert, President Benjamin Haberthur, Executive Director

(630) 232-5980 Fax: (630) 232-5924 www.kaneforest.com

APPLICATION FOR PAYMENT FORM

Project Name:____________________________________________Date:______________________

Contractor:______________________________________________Payment Application #_______

Period Work Completed:___________________________________Change Order #_____________

1 2 3 4 5 6 7 Contractor Work/Material Contracted For

Adjusted Total Contract Including Change Orders

Work Completed Materials Stored

Total Retained Including This Application

Previously Paid

Net Amount Now Due Col 3 – Col 4 & 5

Balance Become Due Col 2 – Col 5 & 6

Amt of Original Contract $ ____________________Work Completed (Col 3) $___________________

Extras to Contract $__________________________ Total Retained (Col 4) $_____________________

Total Contract + Extras $______________________ Net Earned (Col 3+Col 4) $__________________

Credits to Contract $_________________________ Previously Paid (Col 5 ) $____________________

Adjusted Total Contract $_____________________ Net Amount Due (Col 7) $____________________

Sworn Statement for Contractor_________________________________________Date:_____________ http://www.kaneforest.com/

Project Name:
Date:
Contractor:
Payment Application:
Period Work Completed:
Change Order:
1:
3:
Contractor WorkMaterial Contracted ForRow1:
Adjusted Total Contract Including Change OrdersRow1:
Work Completed Materials Stored Row1:
Total Retained Including This ApplicationRow1:
Previously PaidRow1:
Net Amount Now Due Col 3 Col 4 5Row1:
Balance Become Due Col 2 Col 5 6Row1:
Contractor WorkMaterial Contracted ForRow2:
Adjusted Total Contract Including Change OrdersRow2:
Work Completed Materials Stored Row2:
Total Retained Including This ApplicationRow2:
Previously PaidRow2:
Net Amount Now Due Col 3 Col 4 5Row2:
Balance Become Due Col 2 Col 5 6Row2:
Contractor WorkMaterial Contracted ForRow3:
Adjusted Total Contract Including Change OrdersRow3:
Work Completed Materials Stored Row3:
Total Retained Including This ApplicationRow3:
Previously PaidRow3:
Net Amount Now Due Col 3 Col 4 5Row3:
Balance Become Due Col 2 Col 5 6Row3:
Contractor WorkMaterial Contracted ForRow4:
Adjusted Total Contract Including Change OrdersRow4:
Work Completed Materials Stored Row4:
Total Retained Including This ApplicationRow4:
Previously PaidRow4:
Net Amount Now Due Col 3 Col 4 5Row4:
Balance Become Due Col 2 Col 5 6Row4:
Contractor WorkMaterial Contracted ForRow5:
Adjusted Total Contract Including Change OrdersRow5:
Work Completed Materials Stored Row5:
Total Retained Including This ApplicationRow5:
Previously PaidRow5:
Net Amount Now Due Col 3 Col 4 5Row5:
Balance Become Due Col 2 Col 5 6Row5:
Contractor WorkMaterial Contracted ForRow6:
Adjusted Total Contract Including Change OrdersRow6:
Work Completed Materials Stored Row6:
Total Retained Including This ApplicationRow6:
Previously PaidRow6:
Net Amount Now Due Col 3 Col 4 5Row6:
Balance Become Due Col 2 Col 5 6Row6:
Contractor WorkMaterial Contracted ForRow7:
Adjusted Total Contract Including Change OrdersRow7:
Work Completed Materials Stored Row7:
Total Retained Including This ApplicationRow7:
Previously PaidRow7:
Net Amount Now Due Col 3 Col 4 5Row7:
Balance Become Due Col 2 Col 5 6Row7:
Contractor WorkMaterial Contracted ForRow8:
Adjusted Total Contract Including Change OrdersRow8:
Work Completed Materials Stored Row8:
Total Retained Including This ApplicationRow8:
Previously PaidRow8:
Net Amount Now Due Col 3 Col 4 5Row8:
Balance Become Due Col 2 Col 5 6Row8:
Contractor WorkMaterial Contracted ForRow9:
Adjusted Total Contract Including Change OrdersRow9:
Work Completed Materials Stored Row9:
Total Retained Including This ApplicationRow9:
Previously PaidRow9:
Net Amount Now Due Col 3 Col 4 5Row9:
Balance Become Due Col 2 Col 5 6Row9:
Contractor WorkMaterial Contracted ForRow10:
Adjusted Total Contract Including Change OrdersRow10:
Work Completed Materials Stored Row10:
Total Retained Including This ApplicationRow10:
Previously PaidRow10:
Net Amount Now Due Col 3 Col 4 5Row10:
Balance Become Due Col 2 Col 5 6Row10:
Contractor WorkMaterial Contracted ForRow11:
Adjusted Total Contract Including Change OrdersRow11:
Work Completed Materials Stored Row11:
Total Retained Including This ApplicationRow11:
Previously PaidRow11:
Net Amount Now Due Col 3 Col 4 5Row11:
Balance Become Due Col 2 Col 5 6Row11:
Amt of Original Contract:
Work Completed Col 3:
Extras to Contract:
Total Retained Col 4:
Total Contract Extras:
Net Earned Col 3Col 4:
Credits to Contract:
Previously Paid Col 5:
Adjusted Total Contract:
Net Amount Due Col 7:
Sworn Statement for Contractor:
Date_2:

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