Subcontractor Back-Charge Form

Document costs charged back to a sub for cleanup, rework, or damages. Print or save.

warning

Template only. Not legal advice. Confirm subcontract terms permit back-charge before issuance.

Back-Charge Number

Issue Date

foundation

Project / Parties

Project Name

GC Name

Subcontractor Name

Sub Contract Reference

Reason Category

Reason Description *

request_quote

Cost Backup

Description	Qty	Unit	Unit Price	Total
				$260.00
				$125.00
Total Back-Charge:				$385.00

Acknowledgment Language

SUBCONTRACTOR BACK-CHARGE

Back-Charge #:

Issue Date: 2026-05-28

Project: —

GC: —

Subcontractor: —

Reason Category: Cleanup

Description

—

Cost Backup

Description	Qty	Unit	Unit Price	Total
Cleanup labor	4	hours	$65.00	$260.00
Dumpster disposal fee	1	ea	$125.00	$125.00
Total Back-Charge:				$385.00

Acknowledgment

The undersigned Subcontractor acknowledges receipt of this Back-Charge documenting costs incurred by [GC] for the work or condition described above. The amount shown will be deducted from the next payment due to the Subcontractor unless disputed in writing within 10 calendar days.

Signatures

General Contractor

Signature / Printed Name

Date

Subcontractor

Signature / Printed Name

Date

Disputed (sub must submit written dispute within 10 calendar days per acknowledgment)