Attachment J.7 Release of Claims Form.pdf

Updated Version: 12/2017

DISTRICT OF COLUMBIA COURTS

Administrative Services Division Office: Gallery Place

616 H Street NW, 6th Floor Washington, DC 20001

Mailing Address: 500 Indiana Avenue NW Washington, DC 20001-2131

DISTRICT OF COLUMBIA COURTS

RELEASE OF CLAIMS

THE CONTRACTOR SHALL COMPLETE AND SUBMIT THIS FORM AND A COPY OF THE

FINAL INVOICE TO THE COTR

The undersigned Contractor, pursuant to the term of contract between the District of Columbia Courts herein referred to as the “Courts” and

________________________________________________________________ herein (Name of Contractor) referred to as the “Contractor” for (Insert Contract Number and Caption):

Located at:_____________________________________________________________________

1. The Contractor hereby certified that there is due and payable by the Courts to the

Contractor under the contract and fully approved modifications the balance of:

$_____________________________(Final Invoice Amount).

2. The Contractor further certified that in addition to the final invoice amount set forth in paragraph 1 above, there are outstanding and unsettled the following items including Retainer fee which the Contractor claims are just and due and owing by the Courts to the Contractor (Itemize claims and amounts due. If none, so state):

1. ____________________________________________________________

2. ____________________________________________________________

3. ____________________________________________________________

4. ____________________________________________________________

3. The contractor further certified that all work required under this contract including work required under all modifications has been performed in accordance with the terms thereof and that there are no unpaid claims for materials, supplies, equipment, or service.

4. Except for the amounts stated in paragraph 1 and 2 above, the Contractor certifies that

Anne B. Wicks Executive Officer

Louis W. Parker Administrative Officer it has received from the Courts all sums of money pursuant to the above mentioned contract and any modifications.

5. That in consideration of the payment of the amount stated in paragraph 1 above, the

Contractor does hereby release the Courts from any and all claims arising under or by virtue of this contract. Except the amount listed in paragraph 2 above, provided however, that if for any reason the Courts does not pay in full the amount stated in paragraph 1 above, said deduction shall not affect the validity of this release. But the amount so deducted shall be automatically included under paragraph 2 above, as an amount which the Contractor has not released but will release upon payment thereof.

The Contractor further certifies that upon receipt of the payment of the amount listed in paragraph 2 above, and any amount with may be deducted from paragraph 1 above, the Contractor will release the Courts from any and all claims arising out of the above contract or any modifications thereof, and will execute such further release or assurance as the Courts may request.

In WITNESS WHEREOF, the Contractor has signed this instrument this _______day of _____________________, 20________.

CONTRACTOR:

(Print or Type Name)

(Signature)

(Official Title)

(Date) (E-mail)

DC COURTS COTR: Certificate of Acknowledgement of Delivery and Acceptance of All Goods and Services (Print or Type Name)

(Signature)

(Official Title)

(Date)