CERTIFICATION OF PRIME CONTRACTOR OR CONSULTANT
I,
(Name)
as
(Title)
of
(Name of Prime Contractor / Consultant)
in making application for issuance of payment under
Invoice No.:
on Contract No.:
do certify that:
A.
B.
C.
No subcontractor, supplier or subconsultant has been used for work performed on this contract.
Each subcontractor, supplier or subconsultant used for work performed on this contract has been paid
all amounts due from any previous progress payment received from New Jersey Schools Development
Authority (SDA). Furthermore, each subcontractor, supplier and subconsultant whose work is
included in this invoice shall be paid within ten (10) calendar days after receipt by this contractor /
consultant of payment by SDA from the proceeds of this payment.
The following subcontractors, suppliers or subconsultants will not be paid for work performed or
materials supplied to the project(s) from the proceeds of this progress payment because there exists a
valid basis under the terms of the subcontractor's, supplier's or subconsultant's contract to withhold
payment from the subcontractor, supplier or subconsultant and therefore payment is withheld. The
valid basis concerns specific work items enumerated in the subcontractor's, supplier's or
subconsultant's contract. All other subcontractors, suppliers or subconsultants have been and will be
paid in accordance with Paragraph B. above.
The undersigned Contractor / Consultant will provide to the subcontractor(s) and/or supplier(s) and/or
subconsultant(s) noted above, written notice of any withholding of payment. The notice will detail the reason for
withholding payment and state the amount of payment withheld. A copy of the notice will be provided to the
bonding company providing the payment and performance bond for the contract, and the NJSDA.
I certify that the foregoing statements made by me are true. I am aware that if any statement made herein
is willfully false or fraudulent, I am subject to punishment as provided by N.J.S.A. 2C:28-1 et seq. or as
otherwise provided by law.
(subcontractor or supplier or subconsultant)
(amount in dispute)
(amount in dispute)
(subcontractor or supplier or subconsultant)
(amount in dispute)
(subcontractor or supplier or subconsultant)
(amount in dispute)
(subcontractor or supplier or subconsultant)
Signature
Title
Date
File:
/o
Form NJSDA 811
Rev. 12/11//09
