Fillable Monthly Payments To Subcontractors/suppliers

Monthly Payments To Subcontractors/suppliers - Page 3

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Contractor Name:

Non-DBE :

DBE:

Reporting Month/Year:

Contract No.:

Dollars Paid to Contractor:

Total Dollars

Dollars Paid this

Total Dollars Paid

√

Company, Contact Person, Email and Phone.

Work performed or materials provided

Commitment

month

Since NTP

I certify that this information accurately reflects actual payments made to Subcontractors, Subconsultants, and Material Suppliers on the above referenced Project, and that all

Suppliers providing goods under this Contract have been listed in the Sales Tax Statements submitted to the City in connection with this Payment Affidavit. If no subcontractors

or suppliers are listed on the preceding chart or Sales Tax Statements, the Contractor certifies that no subcontractors or suppliers were used in performing the Project/Contract

for the payment period indicated.

NOTARY CERTIFICATION

Signature of Authorized Official

Printed Name

Title

Date

Phone Number of Signer

NOTARY CERTIFICATION

Place

STATE OF ___________________________

Seal

COUNTY OF __________________________