The undersigned represents and warrants that it has been paid and has received (or that it will be paid and will receive via proceeds from this pay application) $ 1 as full and final settlement under the contract/agreement dated Date (the Contract) between the undersigned and First Name Last Name(Contractor/Vendor) for the 2 Agreement owned by First Name Last Name (Owner). In consideration for this final payment, and other good and valuable consideration, receipt of which is acknowledged, the undersigned makes the following representations and warranties:
Agreement Date Date
State of 3
Country of 4
Subcontractor Name and Title First Name Last Name , 5
I, First Name Last Name , agree that First Name Last Name came before me this day and informed me that s/he is title of company name , and that s/he, as title , being authorized to do so, executed the foregoing on the behalf of company name .