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P.O. BOX 186
FORT PIERCE, FL 34954
MARTIN/ST. LUCIE: (772) 461-8335
1NDIAN RIVER: (772) 778-9188
FAX.• (772) 465-7665
APPLICATION FOR PAYMENT
Subcontractor Date
PURSUIT BOATS PLANT EXPANSION
Address Project Name
3891 ST. LUCIE BLVD.. FORT PIERCE. FL
Project Location
Phone Fax
*Payment will only be made from an original invoice and payment application*
*NO faxes will be accepted*
ORIGINAL CONTRACT AMOUNT
APPROVED CHANGE ORDERS
REVISED CONTRACT AMOUNT
VALUE OF WORK COMPLETED
LESS RETAINAGE 10
SUBTOTAL
LESS PAYMENTS PREVIOUSLY BILLED
DIRECT PURCHASES DEDUCTION
OTHER:
AMOUNT DUE THIS REQUEST
$
$