ATTACHMENT X: PAYMENT APPLICATION AND CERTIFICATION Excel version is available at PAYMENT APPLICATION AND CERTIFICATION PAYMENT TO: APPLICATION # ADDRESS: INVOICE # PAYMENT PERIOD FROM: PAYMENT PERIOD TO: PROCUREMENT VOUCHER # (for use by # owner) PROJECT NAME PROJECT ID # Contract Payment Status I certify that, to the best of my knowledge and Total Current belief, this Application for Payment with the attached Schedule of Values, represents a true and Activity reasonable estimate of the work performed during a) Original Contract the stated period and I further certify that the work Amount $ completed to date under this contract is in full b) Previous Change accordance with the terms of the Contract. Orders No $ (Net + or-) Contractor: c) New Change Orders $ - (Net + or-) $ - (Net + or-) $ - (Net + or-) d) Adjusted Signature Contract $ d=(a + b + c) Engineer/Architect/Project Manager e) Total Completed to $ Certification: Date - I certify that, to the best of my knowledge, this $ payment application represents a true and correct f) Previous Earnings - statement of the work performed and is in g) Earnings This $ conformance with the terms of the Contract. Application - g=(e - f) $ h) Balance to Finish - h=(d - e) City Project Manager/Engineer/Architect i) Total Retainage $ 0.00% - $ Checked and Approved: $ - -
ATTACHMENT X: PAYMENT APPLICATION AND CERTIFICATION Excel version is available at PAYMENT APPLICATION AND CERTIFICATION TO: PAYMENT APPLICATION # ADDRESS: INVOICE # PAYMENT PERIOD FROM: PAYMENT PERIOD TO: PROCUREMENT # VOUCHER # (for use by owner) PROJECT NAME PROJECT ID # I certify that, to the best of my knowledge and belief, this Application for Payment with the attached Schedule of Values, represents a true and reasonable estimate of the work performed during the stated period and I further certify that the work completed to date under this contract is in full accordance with the terms of the Contract. Contract Payment Status Total Activity Current a) Original Contract Amount $ b) Previous Change Orders No (Net + or-) $ Contractor: c) New Change Orders (Net + or-) $ - (Net + or-) $ - (Net + or-) $ - Signature d) Adjusted Contract $ d=(a + b + c) Engineer/Architect/Project Manager Certification: e) Total Completed to Date $ - I certify that, to the best of my knowledge, this payment application represents a true and correct statement of the work performed and is in conformance with the terms of the Contract. f) Previous Earnings $ - g) Earnings This Application $ - g=(e - f) h) Balance to Finish $ - h=(d - e) City Project Manager/Engineer/Architect i) Total Retainage 0.00% $ - Checked and Approved: $ - $ -
EMS%20-%20Model%20EMSA%2012.12.14.docx