APPLICATION AND CERTIFICATION FOR PAYMENT Produced by Document G702 Page 1 of 2 pages

To (Owner): Project: Application No: 1 Distribution to:

Owner:
Period to: Architect:
From (Contractor) Via Architect: Start date: Contractor:
Architect:
Project No.
Contract For: General Construction Services / Design Build Contract Date:

Contractor's Application for Payment Application is made for Payment, as shown below, in connection with the Contract Continuation sheet AIA Document G703 is
attached.

Change Order Summary 1. Original Contract Sum $0.00

C.O. Authorized Date Approved Description Additions 2. Net Change by Change orders $0.00
Authorization 1 Date Approved $0.00 3. Contract Sum to date $0.00
Authorization 2 Date Approved $0.00 4. Total Complete & Stored to date $0.00
Authorization 3 Date Approved $0.00 Column G on G703
Authorization 4 Date Approved $0.00 5. Retainage:
Authorization 5 Date Approved $0.00 $0.00
a. 10 % $0.00
Authorization 6 Date Approved $0.00 10 % of completed work (Column D&E on G703)
Authorization 7 Date Approved $0.00 b. 10 % $0.00 $0.00
Authorization 8 Date Approved $0.00 10 % 0f Stored Material (Column F on G703)
Totals $0.00 Total Retainage (line 5a + 5b or
Net change by Change Orders Total Change Order amount ==>> $0.00 Total in Column I of G703) $0.00
6. Total Earned Less Retainage $0.00
(Line 4 less Line 5 total)
The undersigned Contractor certifies that to the best of the Contractor's knowledge information and
7. Less Previous Certificates for
the belief he Work cvered by this application for Payment has been complete in accordance with the
Contract Documents, that all amounts have been paid by the Contractor for Work for which previous Payments (line 6 from Prior Certificate) $0.00
certificates for Payment were issued and payments recieived from the Owner, that current payment
shown herein is now due. 8. Current Payment Due $0.00
9. Balance to Finish, Plus Retainage $0.00
(Line 3 less Line 6)

Contractor: State of County of

Subscribed and sworn to before me this Day of , 20 .

Notary Public:
By: Date: My Commission expires:

ARCHITECT'S CERTIFICATE FOR PAYMENT Amount Certified

(Attached explanation if amount is certified differs from the amount applied for.)

In accordance with the Contract Documents, based on on-site observation and the data comprising Architect:
the above application, the Architect certifies to the Owner that to the best of the Architect's By: _________ Date:__________
knowledge, information and belief the Work has progressed as indicated, the quality of the Work is
in accordance with the Contract Documents, and the Contractor is entitled to payment of the This certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the contractor named herein.
AMOUNT CERTIFIED Issuance, payment and acceptance of payment are without prejudeice to any rights of the owner or
Contractor under this Contract.
CONTINUATION SHEET Document G703 PAGE 2 OF 2 PAGES
Document G702 APPLICATION AND CERTIFICATION FOR PAYMENT, containing,
Contractor's Signed, Certification is attached APPLICATION NUMBER:
In Tabulations below, amounts are stated to the nearest dollar. APPLICATION DATE:
Use Column 1 on Contracts where variable retainage for line items may apply PERIOD TO:
ARCHITECT'S PROJECT NO:

A B C D E F G H I
Line DESCRIPTION OF WORK SCHEDULED WORK COMPLETED MATERIAL TOTAL PERCENT BALANCE Retainer
No. VALUE FROM PREVIOUS THIS PERIOD PRESENTLY COMPLETED (G / C) TO FINISH amounts
APPLICATION STORED AND STORED (C-G)
(D+E) (NOT IN TO DATE
D OR E) (D+E+F+)
1 Division # $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

2 Division # $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

3 Division # $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

4 Division # $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

5 Division # $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

6 Division # $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

7 Division # $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

8 Division # $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

9 Division # $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

10 Division # $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

11 Division # $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

12 Division # $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

13 Division # $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

14 Division # $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

15 Division # $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

16 Division # $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

17 $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

18 $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

19 $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

20 Additional Items $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

Total Original Contract sum $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

Add-ons $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

Change order amount total $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

Grand Totals $0.00 $0.00 $0.00 $0.00 $0.00 #DIV/0! $0.00 $0.00

Current Payment request minus retainer amount $0.00 Minus Retainer = $0.00
 Estimating worksheet
Line No. Description Unit Qty/Hrs Cost Total Cost Markup Total Division Total
1 Division # 35.00%
2 $0.00 $0.00 $0.00
3 $0.00 $0.00 $0.00
4 $0.00 $0.00 $0.00
5 Labor estimate Hrs $0.00 $0.00 $0.00 $0.00
6 Division #
7 $0.00 $0.00 $0.00
8 $0.00 $0.00 $0.00
9 $0.00 $0.00 $0.00
10 Labor estimate Hrs $0.00 $0.00 $0.00 $0.00
11 Division #
12 $0.00 $0.00 $0.00
13 $0.00 $0.00 $0.00
14 $0.00 $0.00 $0.00
15 Labor estimate Hrs $0.00 $0.00 $0.00 $0.00
16 Division #
17 $0.00 $0.00 $0.00
18 $0.00 $0.00 $0.00
19 $0.00 $0.00 $0.00
20 Labor estimate Hrs $0.00 $0.00 $0.00 $0.00
21 Division #
22 $0.00 $0.00 $0.00
23 $0.00 $0.00 $0.00
24 $0.00 $0.00 $0.00
25 Labor estimate Hrs $0.00 $0.00 $0.00 $0.00
26 Division #
27 $0.00 $0.00 $0.00
28 $0.00 $0.00 $0.00
29 $0.00 $0.00 $0.00
30 Labor estimate Hrs $0.00 $0.00 $0.00 $0.00
31 Division #
32 $0.00 $0.00 $0.00
33 $0.00 $0.00 $0.00
34 $0.00 $0.00 $0.00
35 Labor estimate $0.00 $0.00 $0.00 $0.00
36 Division #
37 $0.00 $0.00 $0.00
38 $0.00 $0.00 $0.00
39 $0.00 $0.00 $0.00
40 Labor estimate $0.00 $0.00 $0.00 $0.00
 Change Order Calculations
Authorization 1 Authorization 2 Authorization 3 Authorization 4 Authorization 5 Authorization 6 Authorization 7 Authorization 8
Item # CO Request Line Item Description
Date Approved Date Approved Date Approved Date Approved Date Approved Date Approved Date Approved Date Approved

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Totals $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

 Payments
1 $0.00 <==Payments Date Notes

2 $0.00 <==Payments Date Notes

3 $0.00 <==Payments Date Notes

4 $0.00 <==Payments Date Notes

5 $0.00 <==Payments Date Notes

6 $0.00 <==Payments Date Notes

7 $0.00 <==Payments Date Notes

8 $0.00 <==Payments Date Notes

9 $0.00 <==Payments Date Notes

10 $0.00 <==Payments Date Notes

11 $0.00 <==Payments Date Notes

12 $0.00 <==Payments Date Notes

13 $0.00 <==Payments Date Notes

14 $0.00 <==Payments Date Notes

15 $0.00 <==Payments Date Notes

16 $0.00 <==Payments Date Notes

17 $0.00 <==Payments Date Notes

18 $0.00 <==Payments Date Notes

$0.00 Totals to date