New Mexico Unemployment Laws

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					                                                          SUBCONTRACTORS APPLICATION FOR PAYMENT

DATE                                   PERIOD ENDING                                                                                 FCI CONSTRUCTORS OF NEW MEXICO LLC
                                                                                                                                     1427 W AZTEC BLVD SUITE C3
PROJECT NUMBER                                                                                                                       AZTEC NM 87410
                                                                                                                                     TELEPHONE 505-334-7330 FAX 505-334-3933
PROJECT DESCRIPTION
                                                                                                                                                      APPROVAL_________________________________________
                                                                                                         FCI OFFICE USE_____________________________________________
APPLICATION NUMBER
                                                                                                         VIN #__________                                        INVOICE ___________________
SUBCONTRACTOR
                                                                                                         INVOICE DATE_______________________                    PAYMENT DATE______________


                                                                                                                JOB_________________ CODE________________              TYPE______________




                                                                                          WORK COMPLETED                              STORED MATERIALS
   ITEM                                                         SCHEDULED              PREVIOUS                   THIS                      THIS PERIOD          TOTAL COMPLETED &
   NO.      DESCRIPTION OF WORK                                    VALUE             APPLICATIONS             APPLICATION              (ATTACH INVOICES)          STORED TO DATE       %
     1                                                                     0.00                   0.00                      0.00                         0.00                  0.00           0.0%
     2                                                                     0.00                   0.00                      0.00                         0.00                  0.00           0.0%
     3                                                                     0.00                   0.00                      0.00                         0.00                  0.00           0.0%
     4                                                                     0.00                   0.00                      0.00                         0.00                  0.00           0.0%
     5                                                                     0.00                   0.00                      0.00                         0.00                  0.00           0.0%
     6                                                                     0.00                   0.00                      0.00                         0.00                  0.00           0.0%
     7                                                                     0.00                   0.00                      0.00                         0.00                  0.00           0.0%
     8                                                                     0.00                   0.00                      0.00                         0.00                  0.00           0.0%
     9                                                                     0.00                   0.00                      0.00                         0.00                  0.00           0.0%
    10                                                                     0.00                   0.00                      0.00                         0.00                  0.00           0.0%
    11                                                                     0.00                   0.00                      0.00                         0.00                  0.00           0.0%
    12                                                                     0.00                   0.00                      0.00                         0.00                  0.00           0.0%
    13                                                                     0.00                   0.00                      0.00                         0.00                  0.00           0.0%
    14                                                                     0.00                   0.00                      0.00                         0.00                  0.00           0.0%
    15                                                                     0.00                   0.00                      0.00                         0.00                  0.00           0.0%

 TOTALS                                                                        0                     0                           0                          0                      0       #DIV/0!

                                                             TOTAL TO DATE                          PREVIOUS APPLICATIONS                                       THIS APPLICATION
TOTAL COMPLETED AND STORED TO DATE                          $           -                             $             -                                           $            -
VALUE OF STORED MATERIALS                                   $           -                                                                                       $            -
SUBTOTAL                                                    $           -                                $                   -                                  $            -
LESS 10% RETAINAGE                                          $           -                                $                   -                                  $            -
TOTAL EARNED LESS RETAINAGE                                 $           -                                $                   -                                  $            -
LESS PREVIOUS APPLICATIONS                                  $           -
CURRENT PAYMENT DUE                                         $           -


                                                                                       RELEASE
    I hereby certify that the work performed and the materials supplied to date, as shown above, represent the actual value of accomplishment under the terms of the Contract (and
all authorized changes thereto) between the undersigned and FCI CONSTRUCTORS OF NEW MEXICO, LLC. relating to the referenced project.

   I also certify that the payments, less applicable retention, have been made through the period covered by previous payments received from the contractor or (1) all my
subcontractors, (sub-contractors) and (2) for all materials and labor used in or in connection with the performance of the Contract. I further certify that I have complied with Federal,
State and Local tax laws including Social Security Laws, Unemployment Compensations Laws and Workmen's Compensation Laws insofar as applicable to the performance of the
contract.

   This release is given in order to induce payment in the amount of $          -     (net amount paid to date including this period) and upon receipt of said
payment the Subcontractor releases FCI CONSTRUCTORS OF NEW MEXICO, LLC. from any further liability in connection with all materials, labor and services furnished by the
Subcontractor through the pay period indicated.


STATE OF                                                                                                                             Company Name:
                                                                                                                                     Address:
                                                                                                                                     City, State, Zip:
COUNTY OF                                                                                                                            Phone:
                                                                                                                                     Fax:

Subscribed and sworn to before me this_______day of________________20___.

                                                                                                                                     By:
My Commission expires
                                                                                                                                     Title:

Notary Public                                                                                                                        Date:

				
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