_________________________________________________________________________________________
PROJECT:____________________________
PAYMENT REQUEST NO._______________
PERIOD_____________________________20_______, TO______________________________, 20______
DESCRIPTION OF SERVICES:______________________________________________________________
_________________________________________________________________________________________
STATEMENT OF CONTRACT ACCOUNT:
Original Contract Amount $________________
Approved Change Orders $________________
(As per attached breakdown)
Adjusted Contract Amount $________________
Value on contract completed and drawn to date $________________
Value of C. O.s completed and drawn to date $________________
Total value of work completed and drawn date $________________
Previous draws $________________
Amount Due this Request $________________
Balance to Complete $________________
CERTIFICATE OF THE SUBCONTRACTOR:
I hereby certify that the work performed and the material supplied to date, as shown on the above,
represent the actual value of accomplishment under the terms of the Contract (and all authorized
changes thereto) between the Undersigned and Construction Unlimited, Inc. relating to the above
referenced project.
I also certify that payments, less applicable retention, have been made through the period covered by
previous payments received from the contractor, to (1) all my subcontractors (sub-contractors) and (2) for
all material and labor used in or in connection with the performance of this Contract, I further certify I have
complied with Federal, State and Local tax laws including Social Security laws, Unemployment
Compensation Laws and Workers' Compensation Laws insofar as applicable to the performance of this
contract.
Furthermore, in consideration of the payment received, and upon receipt of the amount of this request,
the undersigned does hereby waive, release and relinquish all claim or right of lien which the undersigned
may now have upon the premise above described except for claims of contract and/or change order
work performed to the extent that payment is being retained or will subsequently become due.
Date_______________________________ __________________________________________
Subcontractor
by________________________________________
Authorized Signature
Title:_____________________________________