D & S Builders
2656 Douglas Dam Road
Sevierville, TN 37876
SUBCONTRACTORS PAY REQUEST
TO: D & S BUIILDERS, LLC
DATE: ________________________________________________________
NAME OF SUB CONTRACTOR: ____________________________________ PROJECT NAME: _______________________________________________
STATEMENT OF PIECE OR HOURLY WORK
Item
Quantity
Price Per Unit
Total
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Employee
Hours Worked
Rate
Total
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Material Furnished – Must be accompanied with a corresponding receipt
Item
Total
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Total Amount Requested _____________________________________________
Scope of Work for This Request
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AFFIDAVIT AND WAIVER OF LIEN
The undersigned subcontractor being duly sworn deposes and says that all labor, material and services included in all previous payments have
been fully paid and indebtedness discharged. Monies received from this request will be used for payment of labor, material and services covered by this
request.
Furthermore, in consideration of the payments received and upon receipt of the amount due, the undersigned does hereby waive, release and
relinquish all claim or right of lien which the undersigned may now have upon the premises above described.
Company______________________________________ By____________________________________ Title____________________
This requisition must be received by D & S Builders on or before the 25th day of the month, in order to be included in D & S Builders monthly requisition for payment
from the owner.
Official Use Only: Job #_______________
Division #__________________
Comments_________________________________________________________________________________________________________________________________