SUBCONTRACTOR APPLICATION AND CERTIFICATE FOR PAYMENT

HCS Contract #
TO: Hollister Construction Services FROM: Subcontractor Name: Application #

777 Terrace Avenue Address:

Hasbrouck Heights, NJ 07604 Application Date:

Phone: (201) 393-7500

Fax: (201) 393-8907 Phone: Period To:

PROJECT NAME: HCS JOB #

Line 1 Subcontract Amount: $ -

THIS SECTION FOR HOLLISTER CONSTRUCTION SERVICES USE ONLY

Line 2 Amount of Approved Change Orders to Date: $ -

Line 3 Adjusted Contract Amount: (Line 1 + Line 2) $ -

Line 4 Work Completed to Date: $ -

Line 5 Less Retainage (10%): $ -

Line 6 Amount Earned to Date: (Line 4 - Line 5) $ -

Line 7 Previous Applications for Payment: (Line 6 from previous Application) $ -

Line 8 Net Amount of this Application for Payment: (Line 6 - Line 7) $ -

CONDITIONAL WAIVER AND RELEASE UPON PROGRESS PAYMENT

The undersigned represents that neither it Nor any of its subcontractors or materialmen have filed a Construction Lien, Notice of Unpaid Balance, or Right To File Lien
regarding the Project, or have taken any action to file or perfect a construction lien to the Project for which any labor or materials or both have been furnished.
In consideration of this payment and all previous payments, the undersigned hereby expressly waives, releases and discharges any and all construction liens and the
right to file a notice of Unpaid Balance and/or Right to File Lien pertaining to the Project for which the aforesaid labor and material or both have been furnished by the
undersigned to or for the account of Hollister Construction Services.

Signed: ______________________________________________________ Date:______________________________

(Signature of Officer or Authorized Agent of Subcontractor)

By: ______________________________________________________ Title:______________________________

(Print Name of Officer or Authorized Agent of Subcontractor)

State of _______________________, County of _______________________, BE IT REMEMBERED, that on this _________day of ______________, 2009,
in the County and State aforesaid, personally appeared before me, the subscriber, a Notary Public of the State of _____________________,
___________________________________________________________________(name of Person signing this release) who I am satisfied is the Party Mentioned
in the within instrument, to whom first made known the contents thereof, and thereupon (he/she) signed, sealed and delivered the same as (his/her) voluntary act
and deed for the uses and purposes therein expressed.
_______________________________________________________________
(Signature of Notary Public)

NOTE: APPLICATION FOR PAYMENT WILL NOT BE PROCESSED IF NON-APPROVED CHANGE ORDER REQUESTS ARE ADDED TO SUBCONTRACT AMOUNT.
IMPROPERLY EXECUTED CERTIFICATIONS WILL BE RETURNED WITHOUT REVIEW.
CONTINUATION SHEET Continuation Sheet Page 1 of 1

APPLICATION AND CERTIFICATE FOR PAYMENT Application #

Subcontractor's signed Certification is attached. Application Date:
Period To:
Project Name:
SUBCONTRACTOR: HCS Job Number:

A B C D E F G H I
WORK COMPLETED
MATERIALS
FROM PREVIOUS TOTAL
ITEM SCHEDULED PRESENTLY % BALANCE TO
DESCRIPTION OF WORK APPLICATION THIS PERIOD COMPLETED & RETAINAGE
NO. VALUE STORED (NOT IN (G/C) FINISH (C-G)
(D+E) STORED TO DATE
D OR E)
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -

Totals $ - $ - $ - $ - $ - - $ - $ -
CHANGE ORDERS Change Order Sheet Page 1 of 1

APPLICATION AND CERTIFICATE FOR PAYMENT Application #

Subcontractor's signed Certification is attached. Application Date:
Period To:
Project Name:
SUBCONTRACTOR: HCS Job Number:

A B C D E F G H I
WORK COMPLETED
MATERIALS
FROM PREVIOUS TOTAL
ITEM SCHEDULED PRESENTLY % BALANCE TO
DESCRIPTION OF WORK APPLICATION THIS PERIOD COMPLETED & RETAINAGE
NO. VALUE STORED (NOT IN (G/C) FINISH (C-G)
(D+E) STORED TO DATE
D OR E)
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
$ - - $ - $ -
Change Order Total $ - $ - $ - $ - $ - - $ - $ -

Grand Total $ - $ - $ - $ - $ - - $ - $ -

When billing retainage, enter the

above amount here.