TEXAS DEPARTMENT OF HOUSING AND COMMUNITY AFFAIRS
HOME Investment Partnerships Program
Building Contractor’s Request for Payment
Contract Administrator: Homeowner Name: Homeowner Address: Building Contractor Name: Contract #: Activity #:
I. Building Contractor’s Certification and Request for Payment
I hereby attest: The information presented on this Building Contractor’s Request for Payment is true and complete; Construction and rehabilitation work performed to-date on the above-referenced address has been completed in accordance with the terms and requirements of the HOME Investment Partnerships Program and Texas Department of Housing and Community Affairs (TDHCA); All expenses for which payment is being requested herein are for actual costs incurred on the above-referenced address; Payment due to contractors, subcontractors and vendors for all expenses incurred to date have been paid in full; The services provided do not violate any conflict of interest provisions; and Construction on the above-referenced address did not begin prior to the date of environmental clearance and loan closing. Construction Start Date: Building Permit Date:
. $ .
I hereby request inspection and authorization of payment for work completed to-date in the amount of: Signature of Building Contractor Date
II. Homeowner Certification
I hereby acknowledge that the work performed to-date by the above-referenced Building Contractor has been satisfactorily completed in accordance with the terms of the construction contract. I hereby approve and authorize payment to Building Contractor in the amount of: $ Signature of Homeowner Date
.
III. Inspector’s Certification
I hereby certify:
The work for which Building Contractor is requesting payment has been performed and satisfactorily completed in
accordance with requirements of TDHCA, including all applicable construction standards and specifications. I hereby approve and authorize payment to Building Contractor in the amount of: Signature of Inspector
$
Date
.
IV. Contract Administrator’s Certification
I hereby attest: The work for which Building Contractor is requesting payment has been performed and satisfactorily completed in accordance with requirements of TDHCA, including all applicable construction codes, standards, and specifications; All expenses for which payment is being requested herein are for actual costs incurred on the above-referenced address; The services provided do not violate any conflict of interest provisions. I hereby approve and authorize payment to Building Contractor in the amount of: $ Signature of Contract Administrator Date
.
TDHCA – Portfolio Management & Compliance Form 11.04 – Contractor Request for Payment
Page 1 of 1 2.5.2009