Pay Request for Services Rendered

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Date

Subcontractor (Subcontratista)*

Invoice No. (Número de factura)*

Business Name (Nombre del Negocio)*

Phone (Teléfono)*

Please add your phone number (Por favor agregue su numero de telefono)

Please add your email if you want a confirmation (Por favor agregue su correo electrónico si desea una confirmación)

Copy of your W9 (Copia de W9)*

Accepted file types: pdf, doc, jpg, png, Max. file size: 25 MB.

If you do not provide a Certificate of Liability Insurance, a 3% fee will be deducted from the Total to be paid amount. (Si no proporciona un Certificado de seguro de responsabilidad civil, se deducirá una tarifa del 3% del monto total a pagar.)

Certificate of Liability Insurance (Certificado de seguro de responsabilidad)*

Accepted file types: pdf, doc, jpg, png, Max. file size: 25 MB.

Address work performed (Trabajo de dirección realizado)*

Street Number (Número de calle)*

Street Name (Nombre de la calle)*

Work Item (Elemento de trabajo)*

Amount to be paid (El monto a pagar)*

Work Item (Elemento de trabajo)

Amount to be paid (El monto a pagar)

Work Item (Elemento de trabajo)

Amount to be paid (El monto a pagar)

Work Item (Elemento de trabajo)

Amount to be paid (El monto a pagar)

Work Item (Elemento de trabajo)

Amount to be paid (El monto a pagar)

Total to be paid (Total a pagar)

Add any notes or comments (Agregar notas o comentarios)

Name

This field is for validation purposes and should be left unchanged.

Oscar Ambros Xolo

Contact Name: Ambros Xolo, Oscar

Phone Number: (713) 291-4456

Email Address: oambros@hotmail.com

Mailing Address on File: 594 County Road 3558, Cleveland, TX, 77327