Subcontractor/supplier Application For Payment Template
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12273 NW Professional Drive
Subcontractor/Supplier
Suite 200
Corvallis, OR 97330
Application for Payment
Phone: 541.752.0381
Fax: 541.752.0472
Please attach a copy of your invoice form for your record-keeping purposes. However, request for payment WILL NOT be processed from your invoice
alone. This Application for Payment and the attached Conditional Waiver & Release Form must be submitted to our office by the 20th of the month for
which you are billing, projected through the end of the month.
Subcontractor:
Phone No:
Address:
Fax No:
Project Name:
Project No:
Subcontractors Application for Payment No:
Inv No:
For Period from:
to:
Today's Date:
Cost Code
Job Code
Amt Completed to
Original Contract
Contract Amount
% Comp
Previous Applications
This Application
(Contractor Use
(Contractor Use
Date
Only)
Only)
Total Original
#DIV/0!
-
Cost Code
Job Code
Amt Completed to
Previous
COR Issued
COR Amount
This Application
% Comp
(Contractor Use
(Contractor Use
Date
Applications
Only)
Only)
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Total COR's Issued
#DIV/0!
-
-
-
Revised Contract Total
#DIV/0!
-
-
-
Total Work Completed to Date
-
Less Retention @
5%
-
Gross Total, Less Retention
-
DO NOT WRITE IN THIS SPACE
Less Previous Net Requests
PM Approval
Net Due this Request
-
Vendor #
**Must accompany signed conditional/unconditional Lien Waiver
SC #
JOB #
Acct Type
Phase Code
Gross Amount
Retention
Discount
Net Amount Due
Contractor Use Only - Hold For:
Signed Contract
Lien Release
Liability Certificate
Warranty
O&M's
Drug Policy
Certified Payroll
W/C Certificate
Mfg. Warranty
Other
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Parent category: Business