ILLINOIS COLLEGE
IMPORTANT NOTICE
DISCLOSURE OF THIS INFORMATION IS
MANDATORY IN ACCORDANCE WITH THE
CONTRACT. FAILURE TO COMPLETE THIS
WILL PREVENT PAYMENT FOR WORK
COMPLETED AND/OR BE A MATERIAL
BREACH OF CONTRACT.
Payment Approved
Date of Pay Meeting
CASS
Contractor’s Affidavit and Sworn Statement
Application No.:
Project No.:
Period From
to
A/E
Coor. Contractor
Project Manager
CONTRACTOR: Name, Address
ARCHITECT-ENGINEER: Name
CDB CONTRACT NO.:
CONTRACT WORK:
ITEMS B & D INCLUDE CHANGE ORDER #:
1
Names of Contractor,
Subcontractor & Material Suppliers
For the Several Parts of the Work
3
Name of the Several Parts of
the Work & Material
[Use same breakdown as CSV
(Contractor’s Sched. Of Values)]
Bonds
Insurance
Const. Admin. Fee
Overhead & Profit
MBE/FBE (if applicable)
E
Total Contract
to Date
Schedule of Values
Plus Change Orders
Name:
Project No.:
Contract No.:
C.F. Locale:
Contractor #5
PROJECT: Name, Location
F
Work Completed &
Material Stored
%
FOR ILLINOIS COLLEGE USE ONLY
Dollar Value
G
Total Retained
Including this
Application
N/A
N/A
N/A
I
Previous
Payments
J
New Amount
Requested
Col. F minus
(Col. G + I)
K
Balance to
Become Due.
Col. E minus
(Col. I + J)
N/A
N/A
N/A
SUBTOTAL
TOTAL (All Pages)
A Original Contract Sum
B Change Orders – Total Additions
C Subtotal
D Change Orders – Total Deductions
E Total Contract to Date
F Total Complete to Date
G Less
% Retainage
H Net Amount Requested
I Less Previous Payments
J New Amount Requested
K Balance to Become Due
$
$
$
$
$
$
$
$
$
$
$
A
B
C
D
E
F
G
H
I
J
K
AFFIANT SWEARS
□ Corporation
□ Sole Proprietorship
1. that he is the duly authorized agent of
□ Partnership
□ Joint Venture
2. that any accompanying waivers of lien or previously presented waivers of lien are genuine and have not been delivered
conditionally.
3. that a lien waiver has been submitted for any subcontractor or material supplier whose participation exceeds $500.
4. that the contractor shall save and hold harmless Illinois College or any claimant by, through or under Illinois College
for any misstatement in the above.
Further Affiant sayth nought.
Subscribed and sworn to before me this
Notary Public
Page 1 of 2
Authorized Agent
day of
CASS
Contractor’s Affidavit and Sworn Statement (Cont’d)
Application No.:
Project No.:
T
Period from :
O
1
3
Names of Contractor,
Name of the Several Parts
Subcontractor & Material Suppliers ofthe Work & Material
For the Several Parts of the Work
[Use same breakdown as
CSV(Contractor’s Sched.
Of Values)]
IMPORTANT NOTICE
DISCLOSURE OF THIS INFORMATION IS MANDATORY IN
ACCORDANCE WITH THE CONTRACT. FAILURE TO COMPLETE
THIS WILL PREVENT PAYMENT FOR WORK COMPLETED
AND/OR BE A MATERIAL BREACH OF CONTRACT.
E
Total Contract
to Date
Schedule of Values
Plus Change
Orders
F
Work Completed &
Material Stored
% Dollar Value
SUBTOTAL BROUGHT FORWARD
TOTAL OR SUBTOTAL
Page 2 of 2
G
Total Retained
Including this
Application
I
Previous
Payments
J
New Amount
Requested
Col. F minus
(Col. G + I)
K
Balance to
Become Due.
Col. E minus
(Col. I + J)