Subcontractor Comptroller's Certificate (8 1/2 X 14)

Certificate of Subcontractor to the Comptroller or

Financial Officer of The City of New York

Under the provisions of Section 220-a of the Labor Law of the State of New York, and the terms and conditions of Contract ...... with The Department of Design and Construction of The City of New York, and ...... as contractor, the undersigned SUBCONTRACTOR hereby certifies to the Comptroller and the Director of Finance of The City of New York that the following is a true and correct statement of the amounts now due from the said SUBCONTRACTOR to laborers for daily or weekly wages on account of labor performed upon the work under the aforementioned contract, and the material and/or supplies delivered for use on the work, and for which payment is due, to wit:

AMOUNTS DUE FOR:
NAMES / Labor / Material & Supplies

(Note: If no money is due to any laborers, state above "None due to laborers." If no money is due to other persons for material and/or supplies delivered for use on the work, state above "None due to materialmen and supplymen.")

That the following is a true and correct list of all subcontractors who have employed laborers and/or used materials and/or supplies for work performed under said contract:

NAMES OF SUBCONTRACTORS / WORK SUBCONTRACTED

(Note: If no subcontractors are employed, state above "None.")

......

Subcontractor

By......

President

STATE OF NEW YORK,
COUNTY OF...... / } / ss.:

...... , being duly sworn, deposes and says that he is the SUBCONTRACTOR named in and who executed the foregoing; that he has read the foregoing statement subscribed by him and knows the contents thereof, and that the same is true of his own knowledge and is executed under the provisions of Section 220-a of the Labor Law of the State of New York, and the terms and conditions of Contract ...... with The Department of Design and Construction of The City of New York.

......

Sworn to before me this ...... President

day of ...... , 19......

......

Notary Public, County of......

Note: A CountyClerk's notarial certificate must accompany this
document if it is executed outside the State of New York

Rev. 2/24/97