Subcontractor Requisition For Payment
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1S
R
F
P
UBCONTRACTOR
EQUISITION
OR
AYMENT
S
R
F
P
UBCONTRACTOR
EQUISITION
OR
AYMENT
** T
,
,
A.I.A.
G702
G703
. **
HIS FORM
PROPERLY COMPLETED
INCLUDING
FORM
AND
MUST ACCOMPANY EVERY PAYMENT REQUEST FOR THIS PROJECT
C
/ C
M
S
ONTRACTOR
ONSTRUCTION
ANAGER
UBCONTRACTOR
P
N
:
S
#:
V
#:
ROJECT
AME
UBCONTRACT
ENDOR
___________________________
D
R
: _________
I
#: ___________________
P
R
N
:
ATE OF
EQUEST
NVOICE
AYMENT
EQUEST
UMBER
P
F
P
P
F
____________
____________
ROGRESS
INAL
AYMENT
ERIOD
ROM
TO
STATEMENT OF SUBCONTRACT
S
$
F
:
UBCONTRACT
OR
O
S
D
:
RIGINAL
UBCONTRACT
ATE
A
$
C
# ________ T
# ________
PPROVED
HANGES
HROUGH
M
AXIMUM
TOTAL S
B
$
D
ILLING
UBCONTRACT TO
ATE
STATEMENT OF REQUISITION
GROSS B
R
N
B
ILLING
ETAINAGE
ET
ILLING
C
TO DATE
$
$
$
OMPLETED
L
P
R
$
$
$
ESS
REVIOUS
EQUISITION
CURRENT R
$
$
$
EQUISITION
CERTIFICATION, WAIVER, AND RELEASE
In support of this Requisition seeking payment from Contractor/Construction Manager (“Contractor”) under the Subcontract and for the Project defined
above, I hereby certify on behalf of Subcontractor as follows:
1.
This Requisition seeks payment for the actual value of accomplishments (work performed and materials supplied) to the end of the covered
payment period under the terms of the Subcontract, including all authorized changes thereto.
2.
Subcontractor has made payment in full, less applicable retention, through the period covered by previous requisitions, for all sums owed
relating to the Subcontract (including, without limitation, materials, goods, equipment, labor, union fringes or deductions, and lower-tier
subcontracted work).
3.
Subcontractor has complied with all applicable federal, state, and local tax and/or labor laws, (including, without limitation, Social Security,
unemployment, workers' compensation, and prevailing wage) relating to the Subcontract.
4.
Subcontractor warrants and represents that it has made no assignment of its rights to payment or to file a lien in connection with the Project.
5.
Subcontractor hereby approves any change order document issued by Contractor covering work for which payment is sought in whole or in
part by this Requisition, even if Subcontractor has not yet executed the change order document.
6.
The person signing below has authority from Subcontractor and has personal knowledge that this Requisition and all statements herein are
true and correct.
For valuable consideration, Subcontractor hereby waives and releases any and all claims and/or lien rights which Subcontractor may now have relating
to the Subcontract, through the payment period covered by this Requisition. This waiver and release is unconditional, except that it is conditional on
receipt of payment to the extent of funds sought by this Requisition.
Date: ____________________
SUBSCRIBED AND SWORN TO, BEFORE ME, THIS
__________ day of ______________________________
B
:
Y
Notary Public __________________________________
______________________________________________
My Commission Expires:
B
:
Y
_________________________
______________________________________________
FOR OFFICE USE ONLY:
Approved By: ____________________
Comments: _______________________________________ (Rev 07/13)
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