Construction Reimbursement Form

CONSTRUCTION REIMBURSEMENT FORM

Property Identification

Property Address:

Parties

Project and Contract Information

Project Name:   Contract / PO No.:

Change Order Number (if applicable):   Date of Work:

Itemized Expenses

Provide an itemized list of all costs for which reimbursement is requested. Attach invoices, receipts, lien waivers and any approved change orders. Amounts must be in U.S. dollars.

Attachments / Documentation

Check all documents attached to support this reimbursement request:

Certifications, Representations and Conditions

Claimant certifies under penalty of perjury that all work and materials for which reimbursement is requested were performed and supplied in accordance with the contract documents, approved change orders and applicable laws and codes. Claimant represents that all supplied invoices and receipts are true and correct and that to the best of Claimant's knowledge no liens exist against the property arising from the items claimed, except as disclosed in writing below.

Claimant further warrants that all subcontractors and suppliers have been paid for the amounts covered by submitted invoices or that conditional lien releases in favor of the Payor are attached. Claimant agrees to indemnify and hold harmless the Payor from any claims, liabilities or costs arising from failure to pay subcontractors or suppliers for work or materials claimed herein.

Payment terms: Payor agrees to review submitted documentation and, subject to compliance with the contract and applicable holdbacks, remit payment within the time period required by the controlling contract or, absent a controlling provision, within thirty (30) calendar days of Payor's acceptance of this reimbursement request. Payor may withhold amounts for defective work, unresolved claims, or amounts reasonably necessary to protect Payor's interests.

Inspection and Audit: Payor reserves the right to inspect the completed work and supporting documentation and to audit Claimant's records related to the claimed expenses. Claimant shall retain records for a period of not less than three (3) years following final payment.

Governing Law and Remedies: This request and any dispute arising hereunder shall be governed by the laws of the state in which the property is located. Remedies are cumulative and the prevailing party in any action to enforce rights under this form shall be entitled to recover reasonable attorneys' fees and costs.

Entire Agreement: This Construction Reimbursement Form, together with the contract documents and any approved change orders referenced herein, constitutes the entire agreement between the parties with respect to reimbursement and supersedes prior oral or written statements on the same subject.

Administrative Information

Date of Request:

Claimant Declaration

I certify that the information contained in this request is accurate, that required supporting documentation is attached, and that I am authorized to submit this reimbursement request on behalf of the Claimant named above.

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