AFFIDAVIT CERTIFYING PAYMENT TO ALL SUBCONTRACTORS DEPARTMENT OF FINANCE

FORM 7 AFFIDAVIT
(PROJECT NAME) (PROJECT LOCATION) (PROJECT OR CONTRACT NUMBER) AFFIDAVIT
(THIS AFFIDAVIT SHOULD CONTAIN THE FOLLOWING INFORMATION PRINTED ON

1 AFFIDAVIT OF TRANSLATION FILED IN FAMILY COURT OF
1 AFFIDAVIT OF TRANSLATION OF MARRIAGE CERTIFICATE FAMILY LAW
3 FORM 59 RULE 2902(1) AFFIDAVIT NO

Exhibit “A”

AFFIDAVIT CERTIFYING

PAYMENT TO ALL SUBCONTRACTORS

Department of Finance and Administration

Bureau of Building, Grounds and Real Property Management

I acknowledge that, pursuant to Miss. Code Ann. §31-5-25 and H.B. 1562, Laws of 2002,

that I am required to submit monthly certification indicating payments to subcontractors on prior payment requests. I, the undersigned Contractor, do hereby certify that I have paid the following amounts to subcontractors for Work which has been performed and incorporated into previous Applications for Payment which were issued and payment received from the Owner on the project listed below. I understand that this document must be submitted on a monthly basis after the submittal, approval and payment of Application for Payment #1. I understand that the Bureau of Building reserves the right to require me, the undersigned, to provide verification of payment and/ or additional information.

Division O

Section 00800 SUPPLEMENTARY CONDITIONS

Article 9.6 Progress Payments

Article 9.6.8.1

Pursuant to Code §31-5-25 and HB1562, Laws of 2002

. . .Contractors shall submit monthly certification to the project engineer or architect indicating payments to subcontractors on prior payment request. . . .

Project Name and Number:

Using Agency:

Subcontractor: Amount: $

Page 2 of 2

DFA/Bureau of Building

Affidavit Certifying Payment Form

Subcontractor: Amount: $

(Attach additional list of subcontractors and amounts, if necessary)

Contractor Name and Title:

Contractor Certificate of Responsibility Number:

Contractor Signature: Date:

________________________________________________________________________

State of Mississippi

COUNTY OF

SWORN TO AND SUBSCRIBED BEFORE ME, the undersigned notary public,

this the day of , 20 .

NOTARY PUBLIC

My Commission Expires:

AFFIDAVIT 2 DOCKET NO 201600084 STATE OF MAINE PUBLIC
AFFIDAVIT AS TO POWER OF ATTORNEY BEING IN FULL
AFFIDAVIT CERTIFYING PAYMENT TO ALL SUBCONTRACTORS DEPARTMENT OF FINANCE

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