Final Sales Tax Affidavit Page 3
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10FINAL REQUEST FOR PAYMENT
FINAL
DRAW (INVOICE) #:
__________________________
DRAW DATE:
__________________________
PERIOD END DATE:
______________________________
CONTRACT #:
______________________________
PROJECT:
______________________________
LOCATION:
6877 Phillips Industrial Blvd. Jacksonville, FL 32256 (904) 292-3300
OFFICE USE ONLY
……………………………………$__________________
a)
Amount of original contract
……………………………………$__________________
b)
Net Change Orders #1 thru #_______
……………………………………$__________________
c)
Revised contract amount (a+b)
……………………………………………… $__________________
d)
Work completed to date
………………………… $__________________
e)
Value of stored materials (itemized inventory attached)
………… ………………………… $__________________
f)
Total completed & stored to date (d+e)
……..………. $__________________
Less previous NET applications (line f from previous draw)
g)
$__________________
Current application (f-g) (RETAINAGE)
h)
………………………… $__________________
j)
Less other deductions (2% state if applicable)
………………………………….. $__________________
k)
Net amount this request (h-j)
CONDITIONAL FINAL RELEASE AND WAIVER
JOB:_________
Pursuant to the agreement between SUMMIT CONTRACTING GROUP, INC. and______________________(Subcontractor/Vendor)
for the work on the ___________________________(Project) Subcontractor/Vendor accepts $______________ as payment in FULL
for all work completed and all materials supplied for the above referenced Project only.
In consideration of this payment from SUMMIT CONTRACTING GROUP, INC., Subcontractor/Vendor hereby waives all lien rights,
bond claims and any other claims for labor performed or materials furnished.
The undersigned warrants that no assignment of any liens or claims or the right to perfect a lien against the real property
located at the Project by virtue of the receipt of this payment, has or will be made, and the undersigned has the right to execute this
Release and Waiver. The undersigned also warrants and affirms that all laborers employed by the Subcontractor/Vendor
in connection with the construction of improvements on the above described real property have been paid.
SIGNATURE MUST BE NOTARIZED OR WITNESSED BY TWO PERSONS.
Witness the hand and seal of the undersigned this _________ day of _____________________________,20_______
By:
Name of Company
Signature
Title
Address
Phone
Before me, the undersigned authority, personally appeared __________________________ who, by me being first duly sworn, did acknowledge that
he or she is the ____________________ of _________________________ and as such has the authority to execute this document and that the facts
stated therein are true.
Dated this _________ date of _______________________, 20________. My Commission Expires: ______________________________________
___________________________________
STATE OF __________________ COUNTY OF __________________
Witness:
________________________________________
___________________________________
Notary Public
CHECK DELIVERY (CIRCLE ONE) * DELIVER TO JOB SITE * REGULAR MAIL * OVERNIGHT-FEDEX/UPS #____________________________
OFFICE USE ONLY
W-9 (FED ID #)
SWORN STATEMENT
CONTRACT
INSURANCE
PM APPROVAL
LICENSES/BOND
CO'S
VP APPROVAL
RELEASES
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