Florida Form 4 - Request For Final Payment

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FLORIDA FORM 4
REQUEST FOR FINAL PAYMENT
For completion of work as of ______________________.
CONTRACT AMOUNT
COMPLETE TO DATE
Original Contract Sum
____________________
____________________
Change Orders
____________________
____________________
Totals to Date
____________________
____________________
Less Previous Payments
____________________
AMOUNT DUE THIS REQUEST
===================
FINAL LIEN WAIVER AND AFFIDAVIT
_______________________________________________ being duly sworn, deposes and says that ________ is the ______________________
(Officer’s Name)
(he/she)
(Title)
of
______________________________________________________
and
that
______
makes
this
affidavit
on
behalf
of
(Subcontractor)
(he/she)
____________________________________________________________________ having entered into an Agreement with Benning Construction
(Subcontractor)
Company, the General Contractor, for performing all ___________________________________________________________________________
(Description of work)
on _________________________________ _____________________located at ____________________________________ and is owned by
(Job Name)
(Address of job)
___________________________________________________;___________________________ that all labor, materials, and services furnished or
(Name of Owner)
committed on the above named job have been paid in full and all indebtedness paid and discharged in full for the entire Subcontract work performed by the
undersigned pursuant to the foregoing agreement with Benning Construction Company; and that the Subcontract work has been completed in its entirety in
accordance with the plans, specifications, and Contract Documents pertaining thereto. The Undersigned affirms that all requirements of Article 9 of the
subcontract agreement have been fully complied with.
Furthermore the undersigned acknowledges that payment in the amount of $___________constitutes the final payment due the undersigned, and that upon
receipt of the same, the undersigned is paid in full for the entire Subcontract work performed on the above named job including all labor, material,
supervision, alternation, repair, services and/or otherwise in any way connected with the above-referenced job and does hereby release and relinquish all
liens or claims of lien or any right against any labor and/or material payment bond it has upon the foregoing described property and including any claims
for changes to the Work which were not detailed by Subcontractor in a change order request as of the date of this document and which were based on
improvements actually provided by the undersigned through the date of this document.
*Company Name:_______________________
By: IT’S AUTHORIZED REPRESENTATIVE
_____________________________(Seal)
Name:_______________________________
________________________
Title:________________________________
(Witness)
*Benning may rely on the statement of authorization in taking action based on
this document.
________________________
(Address)
Sworn to and subscribed before me
this _____ day of ____________, 20__.
_________________________________
Notary Public
My Commission Expires:
(Affix Seal)

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