Florida Form 3 - Request For Progress Payment printable pdf download

FLORIDA FORM 3

REQUEST FOR PROGRESS PAYMENT

For work completed and materials suitably stored on the site through_________________.

CONTRACT AMOUNT

COMPLETE TO DATE

Original Contract Sum

____________________

Change Orders

____________________

*Totals to Date

____________________

Less 10% Retainage

____________________

Totals Less Retainage

____________________

Less Previous Payments

____________________

Amount Due

____________________

*Attached is a breakdown of costs for work performed to date and materials stored on site.

INTERIM LIEN, WAIVER, RELEASE AND AFFIDAVIT

________________________________________________________________being duly sworn, deposes and says that _______________is the

(Officer’s Name)

(he/she)

________________________________________ of _____________________________________________ ____and that ________ makes this

(Title)

(Sub-Contractor)

(he/she)

affidavit on behalf of ____________________________________________________________________having entered into this agreement with

(Sub-Contractor)

BENNING CONSTRUCTION COMPANY, the General Contractor, for performing all _________________________________________

(Sub-Contract Work

on ___________________________ located at

_____________________________________________; that all labor, materials, and services

(Project)

(Job Address)

furnished or committed on the above named job, pursuant to said Agreement, have been paid in full and all indebtedness and discharged in

full to the date of this affidavit, except: (list all unpaid subs and/or vendors with amount owed shown by each. If none, enter NONE.

_______________________________________________________________________________________________________________________

Effective upon receipt of $_____________ in payment of the amount due in this request, the undersigned forever waives, releases and

relinquishes any and all claims for work performed through the date of this affidavit and forever waives, releases and relinquishes all rights

of lien which the undersigned may now have upon the premises and improvements above described or any claims against the Subcontract

and/or any payment bond of Contractor for labor, materials, general supervision of construction, alteration or repairs, services and/or

otherwise in any way connected with the above named job through the date of this payment request, 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. The Undersigned affirms that all requirements of

Article 9 of the subcontract agreement have been fully complied with.

Furthermore, in payment of the amount due this request, you are authorized and requested to make payment checks jointly to ourselves and

the above listed subs and/or vendors, if any, for amount shown by each with any remaining balance paid to us singularly.

*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.

Sworn to and subscribed before me

this _____ day of ____________, 20__.

By:_________________________________

_________________________________

Notary Public

My Commission Expires:

(Affix Seal)

Florida Form 3 - Request For Progress Payment

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