CERTIFIED APPLICATION FOR PAYMENT OGS Contract No.: INSTRUCTIONS: Complete ALL Payee Information, including Contract No., OGS Project No., and OGS Project No.: Work Order No., and indicate whether this is a Progress or Final Payment. Sign the Payee Certification, in ink, and have signature notarized. Work Order No.: SUBMIT ONE APPLICATION, WITH ORIGINAL SIGNATURES, with each invoice (payment) submission. PROGRESS PAYMENT FINAL PAYMENT Please check one box. Payee Information: Consultant Firm: Remittance or Direct Deposit Address: Federal ID No.: Consultant Project No.: Invoice No.: Invoice Date: Invoice Amt: CERTIFICATION: I certify this Application, attached invoice(s), and documentation are just, true, and accurate; that no part thereof has been paid except as stated, and that the balance is actually due and owing, and that taxes from which is exempt are excluded. Payee Signature (In ink) Title Printed Name Firm Name Sworn before me . this day of 20 Notary Public Required Notary Seal or Stamp for ogs use only (After Invoice Review) Authorized Amount, as indicated on attached Invoice. Initials Refer to attachments for explanation of any adjustments made. Contract End Date All payments are rounded to nearest dollar. Funding Line
CERTIFIED APPLICATION FOR PAYMENT OGS Contract No.: INSTRUCTIONS: Complete ALL Payee Information, including Contract No., OGS Project No., and Work Order No., and indicate whether this is a Progress or Final Payment. Sign the Payee Certification, in ink, and have signature notarized. SUBMIT ONE APPLICATION, WITH ORIGINAL SIGNATURES, with each invoice (payment) submission. OGS Project No.: Work Order No.: Please check one box. PROGRESS PAYMENT FINAL PAYMENT Payee Information: Consultant Firm: Remittance or Direct Deposit Address: Federal ID No.: Consultant Project No.: Invoice No.: Invoice Date: Invoice Amt: CERTIFICATION: I certify this Application, attached invoice(s), and documentation are just, true, and accurate; that no part thereof has been paid except as stated, and that the balance is actually due and owing, and that taxes from which is exempt are excluded. Payee Signature (In ink) Title Printed Name Firm Name Sworn before me this day of 20 . Notary Public Required Notary Seal or Stamp for ogs use only (After Invoice Review) Authorized Amount, as indicated on attached Invoice. Initials Refer to attachments for explanation of any adjustments made. All payments are rounded to nearest dollar. Contract End Date Funding Line
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