Standard Construction Document CCDC 24  1996

APPLICATION FOR PAYMENT

Contractor: Application number: 1
GST registration number:
Date: December 31, 2005
Consultant:
Period covered:
Owner: from Dec 1 to Dec 31

Work: Reference number(s):

title and location

Total value of Work performed & Products delivered to the Place of the
Work at the end of period covered 40,000.00(1)

Total holdback at 10 % $ 4,000 (2)

Holdback released $ 0 (3)

Holdback retained (23) $ 4,000.00(4)

Total amount claimed at the end of period covered (14) $ 36,000.00(5)

Total certified amount from previous certificate for

payment n/a $ 0.00(6)
number and date

Total amount claimed current period (56) $ 36,000.00(7)

Value Added Taxes at 7% $ 2,520.00(8)

Total amount payable current period including Value Added Taxes (7+8) $ 38,520.00(9)

Submitted by the Contractor

name and title of person signing signature