RD3.6: Certificate for Payment

(see FM5:15.4)

Project Name:

Contractor:

Address:

Project Number:

Application Number:

In accordance with the Contract Documents, based upon Project site checks and the data comprising the above-referenced Application For Payment, University's Representative certifies to University that, to its best knowledge, information, and belief, the Work has progressed as indicated in the Application For Payment, the quality of the Work is in accordance with the Contract Documents, and Contractor is entitled to payment of the AMOUNT CERTIFIED.

 

BY UNIVERSITY REPRESENTATIVEBY UNIVERSITY
AMOUNT REQUESTED ON
APPLICATION FOR PAYMENT $ __________

AMOUNT CERTIFIED $ _____________

UNIVERSITY'S REPRESENTATIVE:

 

____________________________________
(Name of Firm)

By: ____________________________________
(Signature)

____________________________________
(Typed or Printed Name)

____________________________________
(Title)

Date: ____________________________________

AMOUNT CERTIFIED $ _____________

TOTAL DEDUCTIONS
(Itemized on page 2 of
this form) $ _____________

TOTAL THIS PAYMENT $ _____________

THE REGENTS OF THE UNIVERSITY
OF CALIFORNIA

By: _________________________________
(Signature)

____________________________________
(Typed or Printed Name)

____________________________________
(Title)

Date: ____________________________________

This Certificate is not negotiable. The "TOTAL THIS PAYMENT" is payable only to Contractor named herein. Issuance, payment, and acceptance of payment are without prejudice to any rights of University under the Contract.

 

DEDUCTION SCHEDULE

Project Number: ____________________________________

Application Number:____________________________________

Amount of Stop Notices filed during this period = $ _________

Liquidated Damages from ____________________________________

to _________ , Phase _________ :

_________ days at $ _________ per day = $ _________

Other:

____________________________________ = $_________

____________________________________ = $_________

____________________________________ = $_________

____________________________________ = $ _________

TOTAL DEDUCTIONS: $ _________

(This amount to be entered on page 1 of the Certificate For Payment form.)

 

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