Subcontractor Application For Payment (Page 2 of 2) in pdf

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: __________________

Subcontractor Application For Payment Page 2