AIA Document G702 - 1992 TM

Application and Certificate for Payment

TO OWNER: PROJECT: APPLICATION NO: Distribution to:
PERIOD TO: OWNER
CONTRACT FOR: ARCHITECT
CONTRACT DATE: CONTRACTOR
FROM CONTRACTORS: VIA ARCHITECT: PROJECT NOS: FIELD
OTHER

CONTRACTOR'S APPLICATION FOR PAYMENT The undersigned Contractor certifies that to the best of the Contractor's knowledge, information
Application is made for payment, as shown below, in connection with the Contract. and belief the Work covered by this Application of Payment has been completed in accordance
Continuation Sheet, AIA Document G703, is attached. with the Contract Documents, that all amunts have been paid by the Contractor for Work for
1. ORIGINAL CONTRACT SUM …………………………………….
$ which previous Certificates for Payment were issued and payments received from the Owner, and
2. Net Change by Change Orders …………………………………….
$ that current payment shown herein is now due.
3. CONTRACT SUM TO DATE (Line 1 ± 2) …….………………….
$ CONTRACTOR:
4. TOTAL COMPLETED & STORED TO DATE (Column G on $G703) By: Date:
5. RETAINAGE: State of:
a. % of Completed Work $ County of:
(Column D + E on G703) Subscribed and sworn to before
b. % of Stored Material $ me this day of
(Column F on G703)
Notary Public:
Total Retainage Lines 5a + 5b or Total in Column I of G703) …………..
$ My Commission expires:
6. TOTAL EARNED LESS RETAINAGE ……………………………..
$

(Line 4 Less Line 5 Total) ARCHITECT'S CERTIFICATE FOR PAYMENT

7. LESS PREVIOUS CERTIFICATES FOR PAYMENT ……………..
$ In accordance with the Contract Documents, based on on-site observations and the data compromising
(Line 6 from prior Certificate) this application, the Architect certifies to the Owner that to the best of the Architect's knowledge,
8. CURRENT PAYMENT DUE ………………………………………..
$ information and belief the Work has progressed as indicated, the quality of the Work is in
9. BALANCE TO FINISH, INCLUDING RETAINAGE accordance with the Contract Documents, and the Contractor is entitled to payment of the
(Line 3 less Line 6) $ AMOUNT CERTIFIED.

CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS AMOUNT CERTIFIED …………………………………………………………$

Total changes approved in previous months by Owner $ $ (Attach explaination if amount certified differs from the amount applied. Initial all figures on this
Total approved this Month $ $ Application and on the Continuation Sheet that are changed to conform with the amount certified.)
TOTALS $ $ ARCHITECT:
NET CHANGES by Change Order $ By: Date:

This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor
named herein. Issuance, payment, and acceptance of payment are without prejudice to any rights of
the Owner or Contractor under this Contract
AIA Document G702TM - 1992. COPYRIGHT © 1953, 1963, 1965, 1971, 1978, 1983 and 1992 by the American Institute of Architects. All rights reserved. WARNING: This AIA Document is protected by U.S. Copyright Law
and International Treaties. Unauthorized reproduction or distribution of this AIA® Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent
possible under the law. Purchasers are permitted to reproduce ten (10) copies of this document when completed. To report copyright violations of AIA Contract Documents, email the American Institues of Architects' legal
counsel, [email protected].
 CONTINUATION SHEET AIA DOCUMENT G703 (Instructions on reverse side) PAGE OF PAGES
AIA Document G702, APPLICATION AND CERTIFICATE FOR PAYMENT, APPLICATION NO.:
containing Contractor's signed Certification, is attached. APPLICATION DATE:
In tabulations below, amounts are stated to the nearest dollar. PERIOD TO:
Use Column I on Contracts were variable retainagle for line items may apply. ARCHITECT'S PROJECT NO.:

A B C D E F G H I
WORK COMPLETED MATERIALS TOTAL BALANCE
ITEM DESCRIPTION OF WORK SCHEDULED FROM PREVIOUS PRESENTLY COMPLETED % TO RETAINAGE
NO. VALUE APPLICATION THIS PERIOD STORED AND STORED (G ÷ C) FINISH (IF VARIABLE
(D+E) (NOT IN TO DATE (C - G) RATE)
D OR E) (D+E+F)

AIA DOCUMENT G703 · CONTINUATION SHEET FOR G702 · 1992 EDITION · AIA® · © 1992 · THE AMERICAN INSTITUTE OF ARCHITECTS, 1735 NEW YORK
AVENUE, N.W., WASHINGTON, D.C. 20006-5292 · WARNING: Unlicensed photocopying violates U.S. copyright laws and will subject the violator to legal prosection. G703-1992

CAUTION: You should use an original AIA document which has this caution printed in red. An original assures that changes will not be obscured as may occur when documents are reproduced.