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    Exhibit D

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    api-162282755

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    Exhibit D

    Uploaded by

    api-162282755
    87 views1 page

    Original Title

    exhibit d

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    Copyright:

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    87 views1 page

    Exhibit D

    Uploaded by

    api-162282755

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    EXHIBIT D

    PAY REQUEST & CONDITIONAL LIEN RELEASE


    PROJECT # / NAME: SUBCONTRACTOR : PAYMENT REQUEST NO.: PERIOD FROM: STATEMENT OF CONTRACT VALUE 1 0-Jan-00 TO 0-Jan-00

    1. Original Subcontract Amount * 2. Approved Change Orders (net) (Add/Deduct) ** 3. Adjusted Subcontract Amount to Date ***

    $ $ $

    0.00 0.00 0.00 Approval

    PROGRESS BILLING 4. Work Completed Subcontract Amount 5. Less Retention to Date 6. Total Work Less Retention 7. Less Previous Payments 8. AMOUNT DUE THIS REQUEST 9. Less Amount Owed to 2nd Tier Subcontractor / Supplier #DIV/0! 0%
    to date ****

    $ ($ $ ($ $ ($ ($ ($ ($

    0.00 Approval 0.00 ) 0.00 0.00 ) 0.00 ) ) ) )

    (Requests are due by the 20th of the Month) Schedule of Values Must Accompany This Request (Exhibit C)

    CERTIFICATE OF THE SUBCONTRACTOR

    To the extent provided below, this document becomes effective to release and the undersigned is considered to waive any notice of lien or right under Utah Code Ann., Title 38, Chapter 1, Mechanic's Liens, or any bond right under Utah Code Ann., Title 14, Contractor's Bonds, or Section 63-56-504 related to payment rights the undersigned has on the above described Property once:
    (1) the undersigned receives a check in the above referenced Payment Amount payable to the undersigned; (2) the check is properly endorsed; and (3) the check is paid by the depository institution on which it is drawn.

    This waiver and release applies to a progress payment for the work, materials, equipment, or a combination of work, materials, and equipment furnished by the undersigned to the Property or to the Undersigned's Customer which are the subject of the Invoice or Payment Application, buy only to the extent of the Payment Amount. This waiver and release does not apply to any retention withheld; any items, modifications, or changes pending approval; disputed items and claims; or items furnished or invoiced after payment period. The undersigned warrants that the undersigned either has already paid or will use the money the undersigned receives from this progress payment promptly to pay in full all the undersigned's laborers, subcontractor's material men, and suppliers for all work, materials, equipment, or combination of work, materials, and equipment that are the subject of this waiver and release. I also certify that payments in full, less applicable retention, have been made through the period covered by the previous payments received from the Contractor, to all my subcontractors, leasee's, consultants, vendors, and others for all materials and labor used in or in connection with the performance of the Contract. I further certify I have complied with all Federal, State, and local laws, including Social Security laws, Unemployment Compensation laws and tax laws insofar as applicable to the performance of the Contract. CONDITIONAL WAVIER AND RELEASE OF LIEN RIGHTS

    Company: Signature: Title: ) :ss. COUNTY OF _______________________ ) STATE OF UTAH

    Date:

    On the ________day of _______, 200__, personally appeared before me the individual who signed the foregoing wavier, who being duly sworn, did say that s/he is the authorized representative and that the execution was the voluntary act and deed of the above named company. Further, if the company is a corporation, the said individual certified that s/he is an officer duly authorized to execute the same on behalf of such corporation.

    Notary Public Exhibit C & D Schedule of Values & Pay Request

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