Form St-C-214-12 - Notice Of Funds Withheld By General Contractor

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ST-C-214-12 (REV.5/12)
NOTICE OF FUNDS WITHHELD BY GENERAL CONTRACTOR
This form is ONLY to be submitted 60 days following the subcontractor’s sales and use tax reporting period
upon completion of each phase of the work:
This is to certify that the undersigned is holding in escrow funds on work performed by the named non resident
Sub- Contractor under the requirements of Section § 48-8-63 of the Official Code of Georgia Annotated:
1. Sub-Contractor’s Name
2. Address
3. Job Location
4. Period Work was in Progress
5. Nature of Work Performed
6. Contract Number (REQUIRED)
7. Amount of Contract
8. Amount of Retainage
9. Contact Name
10. Contact Email
___________________________________________
(Prime or General Contractor)
Date _______________________
___________________________________________
(Signature)
___________________________________________
(Address)
___________________________________________
(E-mail Address)

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