Construction Request Payment Form – Fill Out and Use This PDF

SUBCONTRACTOR’S REQUEST FOR PAYMENT

State of:

County of:

The Undersigned, for and in consideration of payments previously received from Allstate Construction, Inc. and other good and valuable consideration, and in order to induce the above mentioned payment, does hereby waive, release, remise and relinquish the undersigned’s right to claim, demand or impose any lien or liens for work done or materials furnished or any other kind or class of lien whatsoever on the project for which payments have been previously requested and received and/or for which payment is requested above. This document constitutes a waiver of lien by the undersigned in the amount of all sums previously paid by Allstate Construction, Inc. to the undersigned for work done and materials furnished under the above described contract plus the amount of the above requested payment, but shall not operate to release any claim or rights of the undersigned to claim a lien for sums which may hereafter become due the undersigned under the above described contract in excess of the amount of all payments previously received from Allstate Construction, Inc. for work done and materials furnished under the above described contract plus the amount of the payment above requested. As a further inducement to Allstate Construction, Inc. to make the above requested payment, the undersigned hereby certifies, represents and warrants that all materials, labor and services furnished or performed by the undersigned and/or anyone who has furnished materials, labor or services to the undersigned and/or to any Subcontractor with whom the undersigned has contracted in anyway connected with the performance by the undersigned of its obligations under the above described contract have been paid for all material, labor and services rendered through the period covered by the above request for payment. For the separate and specific consideration of 1 dollar in hand paid by Allstate Construction, Inc. to the undersigned, the receipt and sufficiency of which is hereby acknowledged by the undersigned, the undersigned agrees to indemnify and hold Allstate Construction, Inc. harmless from any damages or costs of any nature whatsoever, including attorney’s fees incurred by Allstate Construction, Inc. incident to the removal and/or satisfaction of any lien, claim of lien, or other claim for payment for labor, materials or services furnished in connection with the performance of the above described contract through the end of the period for which payment is requested above by anyone who has furnished labor, materials or services to the undersigned or to any Sub-subcontractor contracting with the undersigned in connection with the performance of the above described contract.