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SUB PROGRESS PAY APPLICATION / RELEASE

MAIL TO : Angeles Contractor, Inc. (Attention: A/P)
8461 Commonwealth Avenue, Buena Park, CA 90621
SUBCONTRACTOR NAME :
SUB ADDRESS :
ACI PROJECT NO. :
PROJECT NAME :
PERIOD FROM : TO :
STATEMENT OF CONTRACT ACCOUNT
Item 1 Original Contract Amount $
Item 2 Approved Change Order Amount (SCA Received) $
Item 3 Adjusted Contract Amount (item 1 plus item 2) $
Item 4 Value Of Work Completed To Date (Attach SOV Approved) $
Item 5 Less Retention (10% of item 4) $
Item 6 Total Less Retention (item 4 minus item 5) $
Item 7 Less Previous Certificates For Payment (item 6 from last pay app) $
Item 8 Amount Due This Request (item 6 minus item 7) $
Item 9 Balance To Finish, Including Retainage (item 3 minus item 6) $

CERTIFICATE OF SUBCONTRACTOR
I hereby certify that the work performed and the materials supplied to date, as shown on the above, represent the actual value of accomplishment under the
terms of the contract (and all authorized changes thereto) between the undersigned and relating to the above referenced project
SIGNATURE OF SUBCONTRACTOR
NAME & TITLE

CONDITIONAL WAIVER AND RELEASE ON PROGRESS PAYMENT AFFIDAVIT OF COMPLIANCE WITH CALIFORNIA PREVAILING
California Civil Code Section 8132 WAGE LAW, CALIFORNIA LABOR CODE SECTIONS 1720-1815
NOTICE: THIS DOCUMENT WAIVES THE CLAIMANT'S LIEN, STOP PAYMENT
NOTICE, AND PAYMENT BOND RIGHTS EFFECTIVE ON RECEIPT OF
PAYMENT. A PERSON SHOULD NOT RELY ON THIS DOCUMENT UNLESS The undersigned, being duly sworn, states that it is a Subcontractor for
SATISFIED THAT THE CLAIMANT HAS RECEIVED PAYMENT. Angeles Contractor, Inc. on the public project listed below, and has complied
Identifying Information with the provisions of the Cal. Labor Code Sections 1720-1815, and has paid
all employees the specified general prevailing rate of per diem wages to its
Name of Claimant: employees, and any amounts due pursuant to Cal. Labor Code 1813. Also,
Name of Customer: Angeles Contractor, Inc. the Subcontractor has employed the required number of apprentices on this
Job Location: project as required. In addition, the undersigned makes this sworn statement
Owner: pursuant to Cal. Labor Code 1775(b)(4) and 1777.7(d)(4).
Through Date:
Conditional Waiver and Release The undersigned has also reviewed the payroll practices of each of
This document waives and releases lien, stop payment notice, and payment bond Subcontractor's lower-tiered subcontractors on this project. Each of
rights the claimant has for labor and service provided, and equipment and material subcontractor's lower-tiered subcontractors has paid the specified prevailing
delivered, to the customer on this job through the Through Date of this document. rate of wages to its employees, has paid any amount due such employees
Rights based upon labor or service provided, or equipment or material delivered, under Cal. Labor Code 1813, has employed the required number of
pursuant to a written change order that has been fully executed by the parties prior apprentices on this project, and has provided subcontractor with an affidavit
to the date that this document is signed by the claimant, are waived and released by that complies with Cal. Labor Code 1775(b)(4) and 1777.7(d)(4).
this document, unless listed as an Exception below. This document is effective only
on the claimant's receipt of payment from the financial institution on which the
following check is drawn: Name of Project:__________________________________
Maker of Check: Angeles Contractor, Inc.
Amount of Check: $ Address of Project:________________________________
Check Payable to:
Exceptions I declare under penalty of perjury under the laws of the State of California
This document does not affect any of the following: that the foregoing is true and correct.
(1) Retentions. Executed this _______________ day of __________________, 20___
(2) Extras for which the claimant has not received payment.
(3) The following progress payments for which the claimant has previously _______________________________________________, California.
given a conditional waiver and release but has not received payment:
Date(s) of waiver and release: _______________________________________ (Subcontractor Name)
Amount(s) of unpaid progress payment(s):
(4) Contract rights, including (A) a right based on rescission, abandonment, or _______________________________________ (Authorized Signature)
breach of contract, and (B) the right to recover compensation for work not
compensated by the payment. _______________________________________ (Name & Title)
Signature
Claimant's Signature:
Claimant's Title:
Date of Signature:

REV: 2.0.3 10/11/2012