appl.for.pay1.1910-8e1.doc

APPLICATION FOR PAYMENT

(Periodic Cost Estimate) Page 1 of 2 pages

2. Official Name and Location of Project:

6. Application No.

8. Date Prepared:

9. Percent Complete:

10. M-M No.

12. Contract Time:

15. Breakdown of Application for Payment

ITEM

NO.

DESCRIPTION OF WORK

PRICE

AMOUNT

16. CONTRACTOR’S Certification: The undersigned CONTRACTOR certifies that: (1) all previous progress payments received from OWNER on account of Work done under the Contract referred to above have been applied to discharge in full all obligations of CONTRACTOR incurred in connection with Work covered by prior Applications for Payment number 1 through ___ inclusive; (2) title to 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, claims, security interest and encumbrances (except such as are covered by Bond acceptable to OWNER indemnifying OWNER against any such lien, claim, security interests or encumbrance) (3) all Work covered by this Application for Payment is in accordance with the Contract Documents and not defective as that term is defined in the Contract Documents; and (4) there are no claims for extra work, delays, omitted items or of any nature against the OWNER or ENGINEER not set forth herein unless expressly stated otherwise in this Application for Payment.

DATE:

CONTRACTOR:

TITLE:

SIGNATURE:

17. Payment of Amount Due CONTRACTOR (Page ___) is recommended.

APPLICATION FOR PAYMENT (Periodic Cost Estimate)

(Continuation Sheet) Page 2 of 2 pages

1. Sponsor’s Name

COMPLETED TO DATE, ORIGINAL CONTRACT ITEMS

COMPLETED TO DATE, CHANGE ORDERS

PLUS MATERIALS ON SITE

TOTAL COMPLETED TO DATE

LESS DEDUCTIONS

(1) Retained (--%)

(2) Liquidated Damages

(3) Retesting

TOTAL AMOUNT DEDUCTED

TOTAL AMOUNT EARNED TO DATE

LESS PREVIOUS PAYMENTS

NET AMOUNT DUE THIS ESTIMATE

STATE SALES TAX (withheld this estimate)

NET AMOUNT DUE CONTRACTOR

ACCOMPANYING DOCUMENTATION:

Application for Payment 1910-8-E1 – Page 1 of 2