JOB NAME:
SUBCONTRACTOR NAME: _
PAYMENT REQUEST NO.:
PAYMENT REQUEST DATE:
PERIOD TO: _
STATEMENT OF CONTRACT
OFFICE USE ONLY
Original Contract Amount
$
1)
Approved Change Orders #1 thru #
$
2)
0.00
New Contract Amount
$
3)
Work completed to date (per attached)
$
4)
Stored Materials (per attached)
$
5)
0.00
Total completed & stored to date
$
6)
0.00
Less previous requests for payment $
7)
0.00
Amount Due this Request
$
8)
0.00
10.00%
Less
% retainage
$
9)
0.00
Less other deductions (if applicable) $
10)
0.00
Net Amount Due this Request
$
11)
0.00
Balance to complete Contract
$
12)
0.00
Retainage held to date
$
13)
CONDITIONAL PARTIAL WAIVER AND RELEASE OF LIEN
The undersigned hereby certifies that the work performed and the materials supplied to date as shown on the above represents the total actual value
of completion under the terms of the Contract (and all authorized changes thereto) between the undersigned and Live Oak Contracting, LLC, relating to
the above referenced project. The undersigned also certifies that payment has been made in full to all my subcontractors and for all materials, labor,
and rental equipment used in or in connection with the performance of this Contract and that none of such laborers and materialmen have any claims,
demands or claims of lien against said premises. The undersigned further certifies compliance with all Federal, State, and local tax laws, including Social
Security and Unemployment compensation laws and Workmen's Compensation insofar as applicable to the performance of this Contract, and do hereby
agree to indemnify and hold Live Oak Contracting, LLC, harmless of and from any and all loss, cost, damage, and expense of any and every kind, including
attorneys' fees, which Live Oak Contracting, LLC, shall or may suffer or incur or become liable for indirectly, out of such improvements, repairs, or other
construction under the contract. Therefore, it is the understanding of the undersigned that this agreement constitutes a Partial Waiver and Release of
Lien against the premises/project only to the extent of the payments certified.
SIGNATURE MUST BE NOTARIZED OR WITNESSED BY TWO PERSONS.
Name of Company
Signature
Title
Address
Phone
20
Subscribed and sworn to, before me this date of
Witness:
Notary Public
Witness:
STATE OF______________________________________COUNTY OF ____________ _______ ___ _________________
: _____________________________________
My Commission Expires
CHECK DELIVERY (CIRCLE ONE) * DELIVER TO JOB SITE * REGULAR MAIL * OVERNIGHT‐FEDEX/UPS # _________________________________________________________
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