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SECTION 00622 - CONTRACTOR ' S APPLICATION FOR PAYMENT ' Application for Payment No . For Work Accomplished through the period of through ' To : Indian River County (OWNER ) From : (CONTRACTOR ) Contract : 4 th Street Widening from US 1 to West of Old Dixie Highway OWNER's Contract No , 9205 ENGINEER : Indian River County Public Work ' s Department tENGINEER' s CONSULTANT : Keith & Schnars . Inc. 1 . Original Contract Price : $ ' 2 . Net change by Change Orders and Written Amendments ( + or - ) : $ 3 . Current Contract Price ( 1 plus 2 ) : $ 4 . Total Work to date : 4 . a Total Work completed to date : $ 4 . b Total material stored to date : $ (1 ) 4 . c Total Work completed and stored to date : (4 . a plus 4 . b ) $ 5 . Retainage ( per Agreement) : 5 . a 10 % of completed Work (0 . 10 x 4 . a ) : $ ' 5 . b 20 % of stored material (0 . 20 x 4 . b ) : $ 5 . c Total Retainage (5 . a plus 5 . b ) : $ 6 . Total Work completed and stored to date less retainage (4 . c. minus 5 . c) : $ 7 . Previous Payments : $ 8 . AMOUNT DUE THIS APPLICATION (6 minus 7 ) : $ (1) Attach detailed schedule and copies of all paid invoices. CONTRACTOR' S CERTIFICATION : ' UNDER PENALTY OF PERJURY, the undersigned CONTRACTOR certifies that ( 1 ) the labor and materials listed on this request for payment have been used in the construction of this ' Work and payment received from the last request for payment has been used to make payments to all subcontractors , laborers , material , men and suppliers except as listed below; (2 ) title of all Work , materials and equipment incorporated in said Work or otherwise listed in or covered by this Application for Payment will pass to OWNER at time of payment free and clear of all Liens , security interests and encumbrances (except such as are covered by a Bond acceptable to OWNER indemnifying OWNER against any such Lien , security interest or encumbrance ) ; ( 3 ) all Work covered by this Application for Payment is in accordance with the Contract Documents and not defective ; and (4 ) If this Periodic Estimate is for a Final Payment to project or improvement, I further certify that all persons doing work upon or furnishing materials or supplies for this project or improvement under this foregoing contract have been paid in full , and that all taxes imposed by Chapter 212 Florida Statutes , ( Sales and Use Tax Act , as Amended ) have been paid and discharged , and that I have no claims against the OWNER . ' Dated By : ( CONTRACTOR) 00622-Contractor's Application for Payment 00622 - 1 R\Public Works\Capital Projects\Fourth Street-Old Dixie-US I \CONTRACT DOCUMENTS\00622-Contractor's Application for Payment.doc