Hasen Exhibit "D" - Schedule Of Values Continuation Sheet - Base Contract Template Page 3
ADVERTISEMENT
1
2
3DOCUMENTS REQUIRED PRIOR TO HASEN PROCESSING PAYMENT REQUEST:
* PAYMENT REQUEST FORM EXHIBIT “D”
* SCHEDULE OF VALUES
* DISCLOSURE AFFIDAVIT
* RELEASE OF MECHANICS LIENS AND CLAIMS FOR ALL COMPANIES LISTED ON THE DISCLOSURE AFFIDAVIT
EXHIBIT "D"
____________________________
Subcontract Agreement No. __________
PAYMENT REQUEST
Date ______________________
From: ___________________________
___________________________
___________________________
To: HASEN Construction Services, Inc.
2900 Photo Avenue
FORT WORTH, TEXAS 76107
PAY REQUEST # _________________
*NOTE: DO NOT BILL FOR CHANGE ORDER ITEMS UNTIL YOU HAVE AN EXECUTED CHANGE ORDER ON FILE
PROJECT DESCRIPTION:
We hereby apply for progress payment on the subcontract covering the ___________________ work for the period
ending ___________________________
1.
ORIGINAL CONTRACT SUM........................................................................ $ _________________________
2.
Net change by Approved Change Orders (see note above).......................... $ _________________________
3.
CONTRACT SUM TO DATE (Line 1 + 2) ...................................................... $ _________________________
4.
% and TOTAL COMPLETED & STORED TO DATE________% ................. $ _________________________
5.
RETAINAGE:
a. ______ % of Completed Work
$_____________
10
b. ______ % of Stored Material
$_____________
10
Total Retainage (Line 5a + 5b) ...................................................................... $ _________________________
6.
TOTAL EARNED LESS RETAINAGE .......................................................... $ _________________________
(Line 4 less Line 5 Total)
7.
LESS AMOUNT PAID TO DATE
(Line 6 from prior Pay Request) .................................................................... $ _________________________
8.
CURRENT PAYMENT DUE ......................................................................... $ _________________________
9.
BALANCE TO FINISH, INCLUDING ANY RETAINAGE
(Line 3 less Line 6)
$_______________
________________________Authorized Signature
_________________________Title
_________________________Print Name
__________________________Date
****DO NOT WRITE BELOW THIS LINE****
______________
___________
___________
________
_________-___
_________________
Gross
Retainage
Net
Job. No.
Contract No.
Job Const Phase
APPROVED BY PROJECT MANAGER: ____________________
DATE: __________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Schedule D-1 (form 1065) - Continuation Sheet For Schedule D (form 1065, 1065-b, Or 8865) - 2011
Financial
Form Att-24 Schedule D - Schedule Of Cigars, Little Cigars, And Loose And Smokeless Tobacco Sold To Federal Military Installations
Financial
Related Categories
Parent category: Business