Pay Request Form
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1CITY OF TALLAHASSEE
CONTRACT PAY REQUEST
1. Date: _________
Payment From: __________ To: ___________
Payment # ___________
Contract # ______________
2. Contractor:
3. Payee: (If different from the Contractor)
4. Contract For:
5. Number of Change Order(s) to date:
Contract Start Date:
6. Original Contract Amount:
Original Completion Date:
7. Change Order (Addition(s)):
Original Contract Time:
(Cal.Days)
8. Change Order (Deduction(s)):
Authorized Extension:
(Cal.Days)
9. Adjusted Contract Amount:
Amended Contract Time:
10. Previous Payment(s):
Amended Completion Date:
11. Balance Before Retainage(line 9-10):
Time Lapsed To Date:
(Cal.Days)
12. Previous Retainage to date:
13. Balance (line 11-12):
14. Work Performed To Date(attach schedule of values):
15. Material Suitably Stored(attach list & invoices):
16. Total To Date (add lines 14&15):
17. Total Retainage:
18. Total Previous Payment(s):
19. Amount Requested(subtract lines 17 & 18 from 16):
CERTIFICATE OF THE CONTRACTOR:
According to the best of my knowledge and belief, I certify that all items and amounts
shown on the face of this Certificate are correct, that all work has been performed and material supplied in full accordance with th
terms and conditions of this Contract. I further certify that all just and lawful bills against the undersigned and his sub-contractors
for labor, material and equipment employed in the performance of this Contract have been paid in full in accordance with their terms
and conditions. I hereby certify that all provisions of Section 446.101 F.S. as amended by,Chapter 72.113 Laws of Florida 1972 regarding
apprentices and payment of wages have been complied with by me and to the best of my knowledge and belief by all sub-contractors
State of:
County of:
(Contractor)
Executed this
day of
AD 19
(Signature)
The foregoing instrument was acknowledged before me this _____ day of __________ 19___, by ____________________
( Name)
who is personally known to me or has produced ____________________________ (as identification) and who did (did not)
(Type of Identification
take an oath. Contractor named above, who, says that the facts contained in the foregoing Certificate of Partial Payment
are true and correct.
_____________________________________________________________________________________________
Notary Public
My Commission Expires
20.
NOTE: THIS SECTION TO BE COMPLETED FOR CONSTRUCTION PROJECT IF APPLICABLE:
PO #
FUND#
CC #
OBJ#
PROJ #
SUB #
AMOUNT $
TOTAL
21. _________________________________ Date: _______ 23.____________________________ Date: _______
Approved By Project Manager
Approved By City Manager
22. _________________________________ Date: _______ 24. ____________________________ Date: _______
Approved By Department Head
Approved By Treasurer-Clerk
Rev. 11/15/99
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