APPLICATION AND CERTIFICATE FOR PAYMENT AIA DOCUMENT G702 PAGE ONE OF PAGES

TO (OWNER): PROJECT: APPLICATION NO: Distribution to:

OWNER
ARCHITECT
PERIOD TO: CONTRACTOR

FROM (CONTRACTOR): VIA (ARCHITECT): ARCHITECT'S

PROJECT NO:

CONTRACT FOR: CONTRACT DATE:

CONTRACTOR'S APPLICATION FOR PAYMENT Application is made for Payment, as shown below, in connection with the Contract, Continuation Sheet,
CHANGE ORDER SUMMARY AIA Document G703, is attached.
Change Orders approved in ADDITIONS DEDUCTIONS
previous months by Owner 1. ORIGINAL CONTRACT SUM $
TOTAL 2. Net change by Change Orders $
Approved this Month 3. CONTRACT SUM TO DATE $
Number Date Approved 4. TOTAL COMPLETED & STORED TO DATE $
(Column G on G703)
5. RETAINAGE
a. _5____% of Completed Work $
(Column D + E on G703)
b. % of Stored Material $
(Column F on G703)
Total Retainage (Line 5A + 5b or
TOTALS Total in Column I of G703) $
Net change by Change Orders 6. TOTAL EARNED LESS RETAINAGE $
The undersigned Contractor certifies that to the best of the Contractor's knowledge, (Line 4 less Line 5 Total)
information and belief the Work covered by this Application for Payment has been completed 7. LESS PREVIOUS CERTIFICATES FOR
in accordance with the Contract Documents, that all amounts have been paid by the Contractor PAYMENT (Line 6 from prior Certificates) $
for work which previous Certificates for Payment were issued and payments received from the 8. CURRENT PAYMENT DUE $
Owner, and that current payment shown herein is now due. 9. BALANCE TO FINISH, PLUS RETAINAGE $
CONTRACTOR: (Line 3 less Line 6)
State of: County of:
Subscribed and sworn to before me this day of
By: Date: Notary Public:
My Commission expires:
ARCHITECT'S CERTIFICATE FOR PAYMENT AMOUNT CERTIFIED $
In accordance with the Contract Documents, based on on-site observations and the data (Attach explanation if amount certified differs from the amount applied for.)
comprising the above application, the Architect certifies to the Owner that to the best of the ARCHITECT:
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 Contractor is entitled to By: Date:
payment of the AMOUNT CERTIFIED. 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.
CONTINUATION SHEET AIA DOCUMENT G703 PAGE OF PAGES
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, containing APPLICATION NUMBER:
Contractor's signed Certification is attached. APPLICATION DATE:
In tabulation below, amounts are stated to the nearest dollar. PERIOD TO:
Use Column I on Contracts where variable retainage for the line items may apply ARCHITECT'S PROJECT NO:

A B C D E F G H I
ITEM DESCRIPTION OF WORK SCHEDULED WORK COMPLETED MATERIALS TOTAL % BALANCE RETAINAGE
NO. VALUE FROM PREVIOUS THIS PERIOD PRESENTLY COMPLETED (G+C) TO FINISH
APPLICATION STORED AND STORED (C-G)
(D + E) (NOT IN TO DATE
D OR E) (D+E+F)