Small Projects Requisition Form	 
Contractor:	     	To:	     	Housing Authority	
	     		     	
	     		     	
Telephone:	     	Telephone:	     	
Fax:	     	Fax:	     	
Email:	     	Email:	     	
Development No.	     	Period Ending:	     	
Contract for:	     	FISH No:	     	

Contractor’s Application for Payment 	Number	     	
Application is made for payment, as shown below in connection with the Continuation Sheet Attached.		
	1.  ORIGINAL CONTRACT SUM	$	     		
	2.  Net change by Approved Change Orders	$	     		
	List On Attached Continuation Sheet				
	3.  CONTRACT SUM TO DATE   (Line 1 + Line 2)	$	     		
	4.  TOTAL COMPLETED & STORED TO DATE	$	     		
	5.  RETAINAGE - 5% of Total Completed and Stored to Date	$ -	     		
	6.  TOTAL COMPLETED LESS RETAINAGE  (Line 4 — Line 5)	$	     		
	7.  LESS PREVIOUS APPROVED CERTIFICATES FOR PAYMENT	$ -	     		
	8.  CURRENT PAYMENT DUE  (Line 6 — Line 7)  	$	     		
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, that all workers used on this project have been paid in accordance with M.G.L. c. 149 §§26-27H, that all subcontractors have been paid in accordance with M.G.L. c.30 §39F,  that the Contractor has complied with all applicable tax laws pursuant to M.G.L. c.62(c) §49(a), and that the current payment shown herein is now due.  Acceptance of the final payment due under this contract shall operate as a release to the Owner, Department and Architect from all claims and liability.	

CONTRACTOR:
     

By:  	Date  	State of                                         County of:                                
On this     day of          200     before me, the undersigned notary public,                                                             personally appeared ,  
proved to me  through satisfactory evidence which were 
                                                         to be the person whose name is signed on the preceding document in my presence
NOTARY SEAL
Notary Public:                                                                               
My Commission expires:	
Architect/Engineer’s Certificate for Payment
In accordance with the Contract Documents, based on site observations and the data comprising the application, the Architect/Engineer certifies to the Owner that to the best of the Architect/Engineer’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.
ARCHITECT/ENGINEER AMOUNT CERTIFIED	$       	
By:	     	Date	     	Attach an explanation if the amount certified differs from the amount claimed due by the Contractor on line 8 above.
Initial all figures on the application and any continuation sheet that changed in accordance with M.G.L. c.30 §39K.	
Title	     				
					
     	     Housing Authority
By:      
Date:       	

	Review/Recommended: RCAT PM
By:      
Date: