CERTIFICATE OF THE SUBCONTRACTOR: FALSE STATEMENTS MAY FORM THE BASIS FOR PERJURY.
I hereby certify that the work performed and the materials supplied to date, as shown in the above, represent
the actual value of accomplishment under the terms of the contract (and all authorized changes thereto) between
the undersigned and Capstone Building Corp. relating to the above referenced project.
Subcontractor hereby waives and releases Capstone Building Corp., its surety, agents, and any other affiliated
company from any and all claims disputes of controversies of whatsoever kind or nature which related to this
Contract, and acknowledges that no other monies are due and owing, or are claimed to be due and owing from
Capstone Building Corp., relating to this contract or breach thereof, except for those monies specifically listed
below (identify any and all disputes).
DESCRIPTION
AMOUNT
I also certify that payments, (except those specifically listed below) less applicable retention, have been made
through the period covered by previous payments received from Capstone Building Corp. to (1) all my
subcontractors (sub-subcontractors) and (2) for all materials and labor used or in connection with the performance
of this Contract. I further certify that I have complied with Federal, State, and local tax laws including Social
Security laws or Unemployment Compensation laws and Worker's Compensation laws, without limitation, insofar
as applicable to the performance of this Contract; and have paid all applicable union obligations. Subcontractors
will hereby indemnify and hold Capstone Building Corp., its surety, agents, and any other affiliated company
harmless from any and all claims, liens, or damages alleged by its sub-subcontractors and suppliers, work force or
other.
DESCRIPTION
AMOUNT
In consideration of the payments received and in order to induce the Contractor to make this payment and
upon receipt of the amount of this request, the undersigned does hereby waive, release, and relinquish all claim
or right of lien which the undersigned may now have upon the premises above described except for claims or
right of lien for contract an/or change order work performed to the extent that payment is being retained or will
subsequently become due.
DATE: ________________________________
_________________________________________________
SUBCONTRACTOR
Subcribed and sworn before me this
BY: _____________________________________________
(Authorized Signature)
______ day of __________________, 20_____
Notary Public: __________________________
TITLE: __________________________________________
My Commission Expires: __________________