Application for Payment – Signature Primus Application for Payment Form Subcontractor Name: Subcontractor Email: Address: City, State: Zip: Phone Number: Fax: Billing Contact: Primus Project Name & NO. Mail To: Primus Contracting Group, Inc.209 Commerce Drive, Ste. 2Ft. Collins, CO 80524970-482-7699 (fax) Primus Contracting Group, Inc. MUST receive an Application for Payment on or before the 25th day of each month to be included in that month's draw to the Owner Period. Payment Request NO. 1. Original Contract Amount $ 2. Approved Change Orders Through NO. $ 3. Adjusted Contract Value $ 4. Total Completed and Stored to Date % $ 5. Less Retainage(please select retainage %) % $ 6. Total Earned Less Retainage $ 7. Less Amount Previously Billed(line 6 from previous application) $ 8. Current Amount Due $ Certificate of the Subcontractor I hereby certify that the work performed and the material supplied to date, as shown on the above, represent the actual value of accomplishment under the terms of the Contract (and all authorized changes hereto) between the undersigned and Primus Contracting Group, Inc. relating to the above-referenced project. I further certify that no labor or materials have been supplied under contracts, agreements, verbal or written, or any other arrangement of any type whatsoever, other than the above contract and executed change orders as noted in Item 2, and the undersigned does hereby release Primus Contracting Group, Inc. from any claim or liability thereof for the period covered by this application. I also certify that payments, less applicable retention have been made through the period covered by previous payments received from the contract to (1) all my subcontractors (sub-subcontractors) and (2) for all materials and labor used in or in connection with the performance of this Contract. I further certify I have complied with Federal, State and local tax laws, including Social Security Laws, Unemployment Compensation Laws and Workmen's Compensation Laws in so far as applicable to the performance of this Contract. (name of subcontractor/supplier) Authroized Signature Subcontractor Title [multistep "2-2"]
