AIA Form G702 & G703 GS702

User Manual: GS702

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APPLICATION AND CERTIFICATE FOR PAYMENT
TO (OWNER):

PROJECT: Alterations to Galion APPLICATION NO:
Community Hospital
Galion, OH
PERIOD TO:

Galion Community Hospital
269 Portland Way South
Galion, OH 44833

VIA (ARCHITECT):

FROM (CONTRACTOR):

CONTRACT FOR:

CHANGE ORDER SUMMARY
Change Orders approve
previous months by Owner

ADDITIONS

DEDUCTIONS

TOTAL

Approved this Month
Date Approved

TOTALS

Net changes by Change Orders

The undersigned Contractor certifies that to the best of the Contractor's knowledge,
information and belief the Work covered by this Application for Payment has been
completed in accordance with the Contract Documents, that all amounts have been
paid by the Contractor for Work for which previous Certificates for Payment were
issued and payments received from the Owner, and that current payment shown
herein is now due.
Construction Manager:

by:

Distribution to:
OWNER
BANK

ARCHITECT'S
The Seckel Group, Ltd. PROJECT NO:
240 Park Avenue West
Mansfield, OH 44902

CONSTRUCTION
MANAGER
ARCHITECT

09g026

CONTRACT DATE:

CONTRACTOR'S APPLICATION FOR PAYMENT

Number

PAGE 1 OF 2 PAGES

Application is made for Payment, as shown below, in connection with the Contract
Continuation Sheet, AIA Document G703, is attached.
1. ORIGINAL CONTRACT SUM
2. Net Change by Change Orders
3. CONTRACT SUM TO DATE (Line 1 +- 2)
4. TOTAL COMPLETED & STORED TO DATE
(Column G on G703)
5. RETAINAGE
a.
of Completed Work
$
(Column D + E on G703)
b.
of Stored Material
$
(Column F on G703)
Total Retainage (Line 5a +5b or
Total in Column 1 of G703
6. TOTAL EARNED LESS RETAINAGE
(Line 4 less Line 5 Total)
7. LESS PREVIOUS CERTIFICATES FOR
PAYMENT(Line 6 from prior Certificate)

8. CURRENT PAYMENT DUE
9. BALANCE TO FINISH, PLUS RETAINAGE
(Line 3 less Line 6 )
State of:
County of:
Subscribed and sworn to before me this the
Notary Public:
My Commission expires:

$
$
$
$

$
$

$

$
$

day of

in the year

.

Dated:

ARCHITECT'S CERTIFICATE FOR PAYMENT
In accordance with the Contract Documents, based on on-site observations and the
data comprising the above application, the Architect certifies to the Owner that to the
best of the Architect's knowledge, information and belief the Work has progressed as
indicated, the quality of the Work is in accordance with the Contract Documents, and
the Contractor is entitled to payment of the AMOUNT CERTIFIED.

AMOUNT CERTIFIED

$

(Attach explanation if amount certified differs from the amount applied for.)
ARCHITECT:
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.

CONTINUATION SHEET

PAGE 2 OF 2 PAGES

AIA Document G703(B), APPLICATION AND CERTIFICATE FOR PAYMENT
containing Contractor's signed Certification is attached.

APPLICATION NUMBER:
APPLICATION DATE:

In tabulations below, amounts are stated to the nearest dollar.

PERIOD TO:

Use Column I on Contracts where variable retainage for line items may apply.
A

B

C

ITEM

DESCRIPTION OF WORK

SCHEDULED

NO.

VALUE

TOTAL

D

ARCHITECT'S PROJECT NO:
E

WORK COMPLETED
FROM PREVIOUS

THIS PERIOD

G

09g026
H

I

TOTAL

%

BALANCE

RETENTION

COMPLETED

G/C

TO FINISH

HELD
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