Date:

Subcontractor / Job Name
Address / Location
City, State, Zip
Phone: Fax: / Job No. / Invoice No.

(1) Original Contract Sum $

(2) Total of APPROVED Change Orders – COPIES $

OF CHANGE ORDERS MUST BE ATTACHED

(3) Adjusted Contract Sum to Date (Line 1 + 2 ) $

(4) VALUE OF CONTRACT WORK PERFORMED $

(Schedule of Values must be attached)

(5) Material Stored on Site $

(6) Value of CHANGE ORDER work performed $

(see attached “schedule of sub-contract change orders”)

(7) Total Billing Value (lines 4 + 5 + 6 ) $

(8) Less Retainage , 10 % per contract ($ )

(9) Less Other Deductions ($ )

(10) Less Previous Applications ($ )

(11) TOTAL AMOUNT OF THIS APPLICATION $

CERTIFICATION AND PARTIAL WAIVER

THE AMOUNT DUE THIS REQUISISTION REPRESENTS A PROGRESS PAYMENT DUE THE UNDERSIGNED UNDER ITS SUBCONTRACT AND EXTRAS WITH HARRELL CONSTRUCTION CO., INC., FOR THE FURNISHING OF ______FOR THE ABOVE REFERENCED PROJECT. IN CONSIDERATION OF PRIOR PAYMENTS RECEIVED AND RECEIPT OF THIS PAYMENT, THE UNDERSIGNED HEREBY RELEASES AND FOREVER DISCHARGES THE SAID HARRELL CONSTRUCTION CO., INC., FROM ANY AND ALL OBLIGATION AND LIABILITIES ARISING BY VIRTUE OF SAID LIENS OF EVERY KIND AND CHARACTER WHATSOEVER AGAINST HARRELL CONSTRUCTION CO., INC., THE OWNER, AND THE ABOVE PREMISES, ARISING OUT OF IN ANY WAY RELATING TO SIAD SUBCONTRACT AND EXTRAS, THROUGH THE DATE OF THIS REQUISITION.

THE UNDERSIGNED CERTIFIES THAT ALL CHARGES FOR LABOR MATERIAL, SERVICES AND OF EVERY OTHER NATURE IN CONNECTION WITH THIS SUBCONTRACT IN THE AMOUNT OF THIS MONTHLY REQUISTION HAVE BEEN PAID IN FULL, AND THAT THERE REMAINS NO CHARGE BY ANY SUBCONTRACTOR, VENDER, OR INDIVIDUALS FURNISHING LABOR OR MATERIALS IN CONNECTION WITH THIS SUBCONTRACT TO DATE FOR WHICH A LIEN COULD BE FILED, ARISING OUT OF OR RELATING TO SAID WORK.

THE UNDERSIGNED HEREBY FURTHER DECLARES AND AGREES THAT IN THE EVENT THAT ANY OTHER LIEN OR CLAIM SHOULD BE BROUGHT AGAINST HARRELL CONSTRUCTION CO., INC., THE OWNER OR THEIR BUILDING OR PREMISES, THE UNDERSIGNED WILL PROTECT THE SAID PARTIES AND DEFEND ANY SUIT OR ACTION BROUGHT AGAINST THEM BY REASON OF ANY LIEN OR OTHER FORM OF CLAIM OR ACTION ARISING OUT OF SAID SUBCONTRACT AND HOLD THEM HARMLESS AND INDEMNIFIED THEREFORM, TOGETHER WITH COURT COSTS AND ATTORNEYS FEES INCURRED BY HARRELL CONSTRUCTION CO., INC..

SIGNED AND SEALED BY THE UNDERSIGNED (IF A CORPORATION, BY ITS DULY AUTHORIZED OFFICER)

THIS______DAY OF ______20_____.

SWORN AND SUBSCRIBED BEFORE ME: SUBCONTRACTOR:

THIS______DAY OF ______20____. ______

BY

______

(NOTARY PUBLIC SEAL) TITLE

Revised 11/10/06