Proof of Payment
Project Information
Project Name:      
Project Street Address:      
Project City, State ZIP Code:      
Organization/Company Information
Organization/Company Name:      
Organization/Company Street Address:      
Organization/Company City, State ZIP Code:      
Organization/Company Telephone Number:      
Organization/Company Tax ID No.:      
Certification
The undersigned hereby acknowledges receipt of the sum of $      as (check one):
	 partial payment for labor, skill, and material furnished.
	 full and final payment for all labor, skill, and material furnished or to be furnished.
	Total Contract Sum:	$	     
	Total Amount Paid to Date (including this payment):	$	     
	Balance of Contract Sum:	$	     

The undersigned affirms that all material furnished by the undersigned has been paid for, and all subcontractors retained by the undersigned have been paid in full.
     	     
Authorized Signatory Printed Name	Title
     	     
Authorized Signature	Date
To complete, sign and return to HRA/PHA for processing.