SUBCONTRACTOR’S APPLICATION FOR PAYMENT From (Company):* Complete Payment Address* Project Name & Location* Phone*Pay Request Number* Pay Period Start Date* Month Day Year Pay Period End Date* Month Day Year STATEMENT OF CONTRACT ACCOUNT:Original Contract Amount*Change Order to Contract Amount to Date*Total Contract Amount*Total Work in Place1%2%3%4%5%6%7%8%9%10%11%12%13%14%15%16%17%18%19%20%21%22%23%24%25%26%27%28%29%30%31%32%33%34%35%36%37%38%39%40%41%42%43%44%45%46%47%48%49%50%51%52%53%54%55%56%57%58%59%60%61%62%63%64%65%66%67%68%69%70%71%72%73%74%75%76%77%78%79%80%81%82%83%84%85%86%87%88%89%90%91%92%93%94%95%96%97%98%99%100%Minus Retaining Percentage Amount*10%5%0%Previous Billed Amount*Total Amount of This Invoice*Total Amount of This Invoice*Total Amount of This Invoice*PLEASE BE AWARE THAT YOU NEED TO BILL RETAINAGE SEPARATELY, AS REFERENCED IN YOUR CONTRACT, OR YOUR APPLICATION WILL BE SENT BACK TO YOU!Certification of Subcontractor* I agree to the followingI hereby certify that the work performed and the material supplied to date, as shown on the above, represent the actual value of accomplishment under the terms of the Contract (and all authorized changes thereto) between the undersigned and RTC, relating to the above-referenced project. I also certify that payments, less applicable retainage, have been made through the period covered by previous payments received from the Contractor, to (1) all my subcontractors and (2) for all materials and labor used in or in connection with the performance of this Contract. I further certify I have complied with Federal, State and local tax laws, including Social Security laws and Unemployment Compensation laws and Worker’s Compensation laws insofar as applicable to the performance of this Contract.Email of Person Signing* Job Title of Person Signing* Today's Date* MM slash DD slash YYYY Your Signature*
