Residential Construction Payment Application
Project Name
Project Address
Owner
Contractor
Application No.
Application Date
Summary
Original Contract Price
Net Change by Change Orders
Total Contract Value
Total Completed & Stored to Date
Retainage
Total Earned Less Retainage
Less Previous Payments
Current Payment Due
Balance to Finish (including retainage)
Schedule of Values
Item No.
Description of Work
Scheduled Value
Work Completed This Period
Work Completed Previous
Total Completed
Balance to Finish
Retainage
Certification
Certified By
Title
Date
Comments / Notes