Payment Receipt Sample - Excel

							                    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
    wendy@davisconstructors.com

6   If you have any questions concerning this pay request please contact Wendy Wesser at
    562-2336.