Robert Malcolm & Associates

Robert Malcolm & Associates_{Quantity Surveyors}

CLAIM FOR PAYMENT
CLIENT'S INFORMATION:
Name:
Address:
Telephone:
Fax:

CLAIM: #	Date of Claim [ ]
Client:
Project Name:
Contractor:
Technical Director:
Consultant/Engineer:
Start Date:
Completion Date:
Original Contract Sum
Limit of Retention

Total Value of work done in BQ
Total Value of Additional work done in BQ Rate
Value of Work Done not in BQ
Materials on Site
Materials off Site
Subtotal A
Additions
Advances	Main Contractor
Prepurchases
Fluctuations: [Materials and Labour]
Subtotal B

Deductions: [Retention Limit]
Amounts Previously Certified
Previous Payment
Sub-total C
Contractors Levy 2%
Amount now Certified for Payment

CLIENT'S NAME
Signature of Client	__________________________
Date:	__________________________

I hereby Recommend the Payment of Claim # for work done in the amount of
Amount:
_______________________________________________________________________________________
_______________________________________________________________________________________
(in Words) is due under the contract referred to above.

Signature of Cleint's Quantity Surveyor/Engineer: _____________________________
Date: __________________