17-Doc 00 62 76 - C-620 Appl for Payment 2007.pdf

Contractor's Application for Payment No.

Application Period: Application Date:

To (Owner): From (Contractor): Via (Engineer):

Project: Contract:

Owner's Contract No.: Contractor's Project No.: Engineer's Project No.:

1. ORIGINAL CONTRACT PRICE............................................................ $

2. Net change by Change Orders................................................................... $

3. Current Contract Price (Line 1 ± 2).......................................................... $

4. TOTAL COMPLETED AND STORED TO DATE

(Column F on Progress Estimate)............................................................. $

5. RETAINAGE:

a. X Work Completed.......... $

b. X Stored Material............ $

c. Total Retainage (Line 5a + Line 5b)................................ $

6. AMOUNT ELIGIBLE TO DATE (Line 4 - Line 5c).............................. $

7. LESS PREVIOUS PAYMENTS (Line 6 from prior Application)......... $

8. AMOUNT DUE THIS APPLICATION................................................... $

9. BALANCE TO FINISH, PLUS RETAINAGE

(Column G on Progress Estimate + Line 5 above).................................... $

Contractor's Certification Payment of: $ is recommended by:

Payment of: $ is approved by:

By: Date: Approved by:

(Date)

(Line 8 or other - attach explanation of the other amount)

(Engineer)

(Owner)

Endorsed by the Construction Specifications Institute.

(Line 8 or other - attach explanation of the other amount)

(Date)

Funding Agency (if applicable) (Date)

Number Deductions

Application For Payment

Montgomery Township 2022-01256.01

Change Order Summary

Gilmore & Associates, Inc.

2022-01256.012022-01256.01

Additions

Whistlestop Park

NET CHANGE BY

Approved Change Orders

TOTALS

CHANGE ORDERS

The undersigned Contractor certifies that to the best of its knowledge: (1) all previous progress payments received from Owner on account of Work done under the Contract have been applied on account to discharge Contractor's legitimate obligations incurred in connection with Work covered by prior Applications for Payment; (2) title of all Work, materials and equipment incorporated in said Work or otherwise listed in or covered by this Application for Payment will pass to Owner at time of payment free and clear of all Liens, security interests and encumbrances (except such as are covered by a Bond acceptable to Owner indemnifying Owner against any such Liens, security interest or encumbrances); and (3) all Work covered by this Application for Payment is in accordance with the Contract Documents and is not defective.

EJCDC C-620 Contractor's Application for Payment © 2007 National Society of Professional Engineers for EJCDC. All rights reserved.