Construction Payment Application
Project Name
Project Number
Date
Owner
Contractor
Application No.
Contract Description & Address
Item No.
Description of Work
Scheduled Value
Previous Work Completed
This Period
Total Completed
Balance to Finish
Retainage (%)
Total Contract Value
Total Earned This Application
Less Retainage
Total Due
Comments / Notes
Authorized Contractor Signature
Date
Owner's Representative Signature
Date