AIA Form G702 & G703 GS702
User Manual: GS702
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Page Count: 2
APPLICATION AND CERTIFICATE FOR PAYMENT PAGE 1 OF 2 PAGES
TO (OWNER): Galion Community Hospital PROJECT: Alterations to Galion APPLICATION NO: Distribution to:
269 Portland Way South Community Hospital OWNER
Galion, OH 44833 Galion, OH
PERIOD TO: BANK
FROM (CONTRACTOR): VIA (ARCHITECT): ARCHITECT'S
The Seckel Group, Ltd. PROJECT NO: 09g026
240 Park Avenue West ARCHITECT
Mansfield, OH 44902
CONTRACT FOR: CONTRACT DATE:
Application is made for Payment, as shown below, in connection with the Contract
CONTRACTOR'S APPLICATION FOR PAYMEN
T
Continuation Sheet, AIA Document G703, is attached.
CHANGE ORDER SUMMARY 1. ORIGINAL CONTRACT SU
M
$
Chan
g
e Orders approv
e
ADDITIONS DEDUCTIONS 2. Net Change by Change Orders $
previous months by Owner 3. CONTRACT SUM TO DATE (Line 1 +- 2) $
TOTAL 4. TOTAL COMPLETED & STORED TO DATE $
Approved this Month (Column G on G703)
Number Date Approved 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)
TOTALS 7. LESS PREVIOUS CERTIFICATES FOR
Net changes by Change Orders PAYMEN
T
(Line 6 from prior Certificate) $
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 8. CURRENT PAYMENT DUE $
completed in accordance with the Contract Documents, that all amounts have been 9. BALANCE TO FINISH, PLUS RETAINAGE $
paid by the Contractor for Work for which previous Certificates for Payment were (Line 3 less Line 6 )
issued and payments received from the Owner, and that current payment shown
herein is now due. State of: County of:
Subscribed and sworn to before me this the day of in the year .
Construction Manager: Notary Public:
My Commission expires:
by: Dated:
ARCHITECT'S CERTIFICATE FOR PAYMEN
T
AMOUNT CERTIFIED $
In accordance with the Contract Documents, based on on-site observations and the (Attach explanation if amount certified differs from the amount applied for.)
data comprising the above application, the Architect certifies to the Owner that to the ARCHITECT:
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 By: ___________________________________________Date:____________________
the Contractor is entitled to payment of the AMOUNT CERTIFIED. 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.
CONSTRUCTION
MANAGER
CONTINUATION SHEET PAGE 2 OF 2 PAGES
AIA Document G703(B), APPLICATION AND CERTIFICATE FOR PAYMENT APPLICATION NUMBER:
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 where variable retainage for line items may apply. ARCHITECT'S PROJECT NO: 09g026
AB CDEGHI
ITEM DESCRIPTION OF WORK SCHEDULED WORK COMPLETED TOTAL % BALANCE RETENTION
NO. VALUE FROM PREVIOUS THIS PERIOD COMPLETED G / C TO FINISH HELD
TOTAL
