HASEN EXHIBIT "D" -SCHEDULE OF VALUES APPLICATION #:

CONTINUATION SHEET - BASE CONTRACT APPLICATION DATE:

Exhibit "D", HASEN's Payment Request amounts are
stated to the nearest dollar. Use Column I on PERIOD TO:
Contracts where variable retainage for line items may HASEN SUBCONTRACT #:
apply.

A. B. C. D. E. F. G. H. I.
Materials Total
Presently Completed Balance to Retainage
ITEM SCHED. Previous Pay %
DISCRIPTION OF WORK This Period Stored and Stored to Finish (if Variable
# VALUE (D + E) (G/C)
(Not in D or Date (C - G) Rate)
E) (D + E + F)

Totals:
CONTINUATION SHEET - CHANGE ORDER
APPLICATION DATE:
Exhibit "D", HASEN's Payment Request amounts are
stated to the nearest dollar. Use Column I on PERIOD TO:
Contracts where variable retainage for line items may
apply. HASEN SUBCONTRACT #:

A. B. C. D. E. F. G. H. I.
Materials Total
Presently Completed Balance to Retainage
ITEM SCHEDULED Previous Pay %
DISCRIPTION OF WORK This Period Stored and Stored to Finish (if Variable
# VALUE (D + E) (G/C)
(Not in D or Date (C - G) Rate)
E) (D + E + F)

Totals:
DOCUMENTS REQUIRED PRIOR TO HASEN PROCESSING PAYMENT REQUEST:
* PAYMENT REQUEST FORM EXHIBIT “D”
* SCHEDULE OF VALUES
* DISCLOSURE AFFIDAVIT
* RELEASE OF MECHANICS LIENS AND CLAIMS FOR ALL COMPANIES LISTED ON THE DISCLOSURE AFFIDAVIT
EXHIBIT "D"

Subcontract Agreement No.

PAYMENT REQUEST
Date
From:

To: HASEN Construction Services, Inc.

2900 Photo Avenue
FORT WORTH, TEXAS 76107 PAY REQUEST #

*NOTE: DO NOT BILL FOR CHANGE ORDER ITEMS UNTIL YOU HAVE AN EXECUTED CHANGE ORDER ON FILE

PROJECT DESCRIPTION:
We hereby apply for progress payment on the subcontract covering the work for the period
ending

1. ORIGINAL CONTRACT SUM........................................................................ $

2. Net change by Approved Change Orders (see note above).......................... $
3. CONTRACT SUM TO DATE (Line 1 + 2) ...................................................... $
4. % and TOTAL COMPLETED & STORED TO DATE % ................. $ _
5. RETAINAGE:
a. _1_0 % of Completed Work $
b. _1_0 % of Stored Material $
Total Retainage (Line 5a + 5b) ...................................................................... $
6. TOTAL EARNED LESS RETAINAGE .......................................................... $
(Line 4 less Line 5 Total)
7. LESS AMOUNT PAID TO DATE
(Line 6 from prior Pay Request) .................................................................... $
8. CURRENT PAYMENT DUE ......................................................................... $
9. BALANCE TO FINISH, INCLUDING ANY RETAINAGE
(Line 3 less Line 6) $

Authorized Signature Title

Print Name Date

****DO NOT WRITE BELOW THIS LINE****

-
Gross Retainage Net Job. No. Contract No. Job Const Phase

APPROVED BY PROJECT MANAGER: DATE: