Payment Application IV FORM

00 60 00 – Standard Contract Administration Forms (Single)

University of Illinois

CONTRACTOR'S PAYMENT APPLICATION - PART III

AFFIDAVIT AND PARTIAL LIEN WAIVER FOR PREVIOUS PAYMENT REQUEST

(Required for the second through final payment requests.)

AFFIDAVIT

STATE OF ILLINOIS
COUNTY OF ______/ )
)SS
)

The Affiant, ______, being first duly sworn, upon the oath deposes and says the following:

1.Identification: The Affiant states that the Affiant is______of ______, hereinafter termed "the Contractor", who is the Contractor for the
______project, hereinafter termed "the Project", constructed for The Board of Trustees of the University of Illinois, hereinafter called "the Owner", under a written agreement dated ______, entered into by and between the Contractor and the Owner, and pertaining to said Work on the Project.

2.Receipt of Previous Payments and Partial Waiver of Lien: The Affiant further states that the Contractor has received payments to date from the Owner totaling ______Dollars ($______), which includes the sum certified under the Contractor's previous partial payment request, and that the Contractor hereby waives all right to a mechanic's lien on the funds and property of the Owner to the extent to which payment has been made. The Contractor, however, reserves all right to a lien against the property or funds of the Owner for such work, labor, or material that is yet to be performed or furnished under the above contract and for any amount or amounts which may yet be due and owing to the Contractor, including retainage held by the Owner. Previously certified payments, if any, that have not been received by the Contractor are stated below:

______

All documents are property of the University of Illinois and may not be modified. Improper use or alteration of any document shall be considered a material breach of the Agreement with the University of Illinois and may result in civil or criminal liability.

Form approved by Legal Counsel - UOCP&RES07/18Page 1 of 3

00 60 00 – Standard Contract Administration Forms (Single)

CONTRACTOR'S PAYMENT APPLICATION - PART III

AFFIDAVIT AND PARTIAL LIEN WAIVER FOR PREVIOUS PAYMENT REQUEST

3.Payments for Work Over $1,000 in Value: The Affiant further states that the following persons or firms in accordance with Articles 6 and 12 of the General Conditions have been contracted with, have done or are doing labor, have furnished or are furnishing materials, or have performed or are performing services on the project of a total value of more than ONE THOUSAND DOLLARS ($1,000.00):

Name of
Subcontractor/
Vendor/Supplier / Subcontract Work,
Materials, or
Equipment Provided / Current Value of
Purchase Order
Or Subcontract / *Total Paid
to Date / *Unpaid Amount
Previously Requested
(incl. retainage) / *Pending
Balance
U / 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
TOTALS / 0 / 0 / 0

*Notes:Pursuant to Articles 6 and 12 of the General Conditions:

1.For all Contractor payment requests except the final, the actual distributions made (or not made) to subcontractors/vendors/suppliers should correspond to amounts requested in the Contractor's previous payment requests.

2.For the Contractor's final payment request, all subcontractors/vendors/suppliers should be paid in full.

3.Provide detailed explanations in section 4 of this form for all payments due to subcontractors from the Contractor's previous payment requests that have not been made in accordance with the abovementioned contract provisions.

00 60 00-1

Single

Form approved by Legal Counsel - UOCP&RES07/18Page 2 of 3

00 60 00 – Standard Contract Administration Forms (Single)

CONTRACTOR'S PAYMENT APPLICATION - PART III

AFFIDAVIT AND PARTIAL LIEN WAIVER FOR PREVIOUS PAYMENT REQUEST

4.Exceptions (Payments Not Made for Work Over $1,000 in Value): The Affiant further states that the amounts set opposite the preceding names have been paid and completely satisfied and that no such person or firm has any claim against the Owner for any labor, materials, or services furnished or work done by them on such account. Exceptions, if any, are stated below:

Firm ______$ / Firm ______$
Firm ______$ / Firm ______$
Firm ______$ / Firm ______$
Firm ______$ / Firm ______$

5.Payments for Work $1,000 or Less in Value: The Affiant further states that all persons or firms who have done or are doing labor, have furnished or are furnishing materials, or have performed or are performing services on the project of the total value of ONE THOUSAND DOLLARS ($1,000.00) or less, have been paid in full and completely satisfied for the labor done, materials furnished, or service performed to the date hereof, and have no claims against the Owner for labor, materials or services done, furnished or performed by them on such account. Exceptions, if any, are stated below:

Firm ______$ / Firm ______$
Firm ______$ / Firm ______$
Firm ______$ / Firm ______$
Firm ______$ / Firm ______$

6.Compliance with the Contract Documents: The Affiant further states that this affidavit is made on behalf of the Contractor for the purpose of complying with the Contract Documents.

Subscribed and sworn to before me this

______day of ______20__.

______/ Contractor ______
Notary Public / By ______
My Commission Expires ______
(Date) / Title ______

00 60 00-8

Single

Form approved by Legal Counsel - UOFP&P 07/18Page 3 of 3