Payment Receipt Sample - Excel
Payment Receipt Sample document sample
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Subcontractor/Supplier Pay Request Project Name CONTRACTOR: Name CONTRACT #: Address 1 PAY APPLICATION #: Address 2 PERIOD TO: Ph: Fax: BILL DATE: GENERAL: Davis Constructors & Engineers, Inc. 740 Bonanza Anchorage, AK 99518 Ph: 907-562-2336 Fax: 907-561-3620 DESCRIPTION OF WORK SCHEDULED % JOB TO DATE VALUE Complete COMPLETED Original Contract #DIV/0! Subtotal 0.00 #DIV/0! 0.00 Change Orders #DIV/0! Subtotal 0.00 #DIV/0! 0.00 Revised Contract Amount/Total Complete 0.00 #DIV/0! 0.00 Less 0% retention 0.00 Total Earned Less Retention 0.00 Less Previous Pay Applications 0.00 Current Payment Due 0.00 PARTIAL LIEN RELEASE The undersigned certifies that the work covered by this Application for Payment has been completed in accordance with the Contract Documents. The undersigned also represents that all those furnishing labor, materials, services or equipment in connection with the project on behalf of the undersigned have been paid and have no claims whatsoever on the project through the last payment received. Upon receipt of the payment referenced above the undersigned waives all lien rights including Stop Notice rights and all claims against bonds and/or retainage for all materials, services and equipment provided through the period above. CONTRACTOR: _____________________________________ Date: _______________ Subcontractor/Supplier Pay Request Form Instructions 1 This subcontractor/supplier pay request format is required for all Davis subcontractors and suppliers. You are welcome to attach your own invoices, however the pay request also needs to be completed and the partial lien release signed. We will bill the owner based upon this pay request, therefore accuracy is very important. 2 If your scope of work entails a schedule of values you will need to coordinate with our office and bill per the agreed upon scheduled line items. 3 Change orders are to be itemized and billed per Davis change order #s. You may add pending change orders to your billings with the understanding that if the change requires owner or Davis approval it may be adjusted. 4 Your pay request must be received in our office by the 25th each month or as required by contract. 5 The electronic version of this pay request is available via email. Send your request to email@example.com 6 If you have any questions concerning this pay request please contact Wendy Wesser at 562-2336.