Contractor Invoice Template (Page 5 of 6) in pdf

Exhibit A-3

AFFIDAVIT OF PAYMENT OF DEBTS AND CLAIMS

AND AFFIDAVIT OF WAIVER/RELEASE OF LIENS

TO: Rochester Institute of Technology

FROM: _________________________

RIT PROJECT : __________________

RIT PURCHASE ORDER: _________

The Undersigned hereby certifies that to the best of the Undersigned's knowledge, information and belief,

except as listed below, all obligations for all materials and equipment furnished, for all work, labor and

services performed, and for all known indebtedness and claims against the Undersigned for damages

arising in any manner in connection with the performance of the Project referenced above for which

Rochester Institute of Technology or its property might in any way be held responsible have been paid in

full or upon receipt of the payment to which this is attached will be paid in full or otherwise satisfied; and

hereby unconditionally waivers, releases and relinquishes all of its rights and covenants to commence an

action for or to claim or file a mechanic's lien or other lien against RIT or its property for such labor,

equipment, and/or materials so furnished by the Undersigned.

The Undersigned further agrees to reimburse and does hold harmless and fully indemnify Owner and its

successors and assigns for any losses or expenses should any such claim, lien, or right to a lien be asserted

by the Contractor or by any person or entity acting for or claiming by, through or under the Contractor,

including, without implied limitation, attorney’s fees incurred in the defense thereof.

The Undersigned, further attests that with respect to this Contract, all required taxes have been set aside and

have been paid or will be paid when due, and all employer contributions required to be paid under labor

agreements have been paid or will be paid when due.

The Undersigned further, hereby certifies that to the best of the Undersigned's knowledge, information and

belief, except as listed below, the release or waivers of lien attached hereto include all contractors, all

subcontractors, all suppliers of material and equipment, and all performers of work, labor and services who

have or may have liens against any property of Rochester Institute of Technology arising in any manner out

of the performance of the Project referenced above.

Exceptions:

CONTRACTOR: ___________________________

By: ______________________________________

Title: _____________________________________

Subscribed and sworn to _____________________

before me this ____ day of ____________, 20____.

Notary Public

F:Design and ConstructionPolicies and ProceduresLien Releases

Rev. 09/28/05

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