Document G702® – 1992
Application and Certificate for Payment
TO OWNER:
PROJECT:
APPLICATION NO: Distribution to:
PERIOD TO:
OWNER
□
CONTRACT FOR:
ARCHITECT
□
CONTRACTOR:
ARCHITECT:
C
ONTRACT DATE:
CONTRACTOR
□
PROJECT NOS: / /
FIELD
□
□
The undersigned Contractor certifies that to the best of the Contractor’s knowledge, information
and belief the Work covered by this Application for Payment has been completed in accordance
with the Contract Documents, that all amounts have been paid by the Contractor for Work for
which previous Certificates for Payment were issued and pa yments received from the Owner, and
that current payment shown herein is now due.
CONTRACTOR’S APPLICATION FOR PAYMENT
Application is made for payment, as shown below, in connection with the Contract.
AIA Document G703®, Continuation Sheet, is attached.
1. ORIGINAL CONTRACT SUM ………………………………………….
$
2. NET CHANGE BY CHANGE ORDERS ………………………… $
3. CONTRACT SUM TO DATE (Line 1 ± 2) ………………………..........
$By: Date:
4. TOTAL COMPLETED & STORED TO DATE (Column G on G703) ……
$ State of:
5. RETAINAGE:
County of:
a.
% of Completed Work
$
Subscribed and sworn to before
me this <Twenty-seventh> day of (Columns D + E on G703)
b.
% of Stored Material
$
Notary Public: (Column F on G703)
Total Retainage (Lines 5a + 5b, or Total in Column I of G703)…... $
My commission expires:
6. TOTAL EARNED LESS RETAINAGE ………………………………
$
ARCHITECT’S CERTIFICATE FOR PAYMENT
(Line 4 minus Line 5 Total)
In accordance with the Contract Documents, based on on-site observations and the data comprising
this application, the Architect cer tifies to the Own er that to the best of the Architect’s knowledge,
information and belief the Work has progressed as indicated, the quality of the Work is in
accordance with the Contract Documents, and the Contract or is entitled to payment of the
AMOUNT CERTIFIED.
7. LESS PREVIOUS CERTIFICATES FOR PAYMENT ………………….
$
(Line 6 from prior Certificate)
8. CURRENT PAYMENT DUE ………………………………………
$
9. BALANCE TO FINISH, INCLUDING RETAINAGE
AMOUNT CERTIFIED .............................................................................
$
(Line 3 minus Line 6) $
(Attach explanation if amount certified differs from the amount applied. Initial all figures on this
Application and on the Continuation Sheet that are changed to conform with the amount certified.)
CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS
ARCHITECT:
Total changes approved in previous months by Owner $ $
By: Date:
Total approved this month $ $
This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor
named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of
the Owner or Contractor under this Contract.
TOTAL
$
$
NET CHANGES by Change Order
$
FROM
VIA
CONTRACTOR:
AIA Document G702® – 1992. Copyright © 1953, 1963, 1965, 1971, 1978, 1983 and 1992 by The American Institute of Architects. All rights reserved. The “American Institute of Architects,” “AIA,” the AIA Logo, “G702,” and
“AIA Contract Documents” are registered trademarks and may not be used without permission. This document was created on under the terms of AIA Documents on Demand® Order
No. , is not for resale, is licensed for one-time use only, and may only be used in accordance with the AIA Contract Documents® Documents-on-Demand - End User License Agreement. To report copyright
violations, e-mail copyright@aia.org
.
C. A. Scism Construction Company
TLG Peterbilt - Greensboro
7061 Albert Pick Rd Greensboro
Daniel Priest, Priest Architectu
