Complete the fourth page after removing carbons (if not MSSICS generated).
Part 1: Obtain the claimant's/recipient's signature and the date of signature for every information
Part 2: If the claimant/recipient is the person upon whose work or service the claim for payment
is based, check the block beside “The Claimant” and enter the requested information
for the claimant/recipient.
If the claimant/recipient is not the person upon whose work or service the claim is
Check the second block, and
Enter the name of the person, and
Show his/her relationship to the person whose work or service is material to the claim.
If answers to any items are not available, enter "Unknown" in the appropriate block.
Part 3: The agency or organization completes this section.