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' STATE OF FLORIDA COUNTY OF : ' Before me , a Notary Public , duly commissioned , qualified and acting , personally appeared , to me well known , who being by me first duly sworn upon oath , says that he/she is the President of the Contractor above mentioned : ; ' the he/she executed the above Application for Payment and statement on behalf of said CONTRACTOR ; and that all of the statements contained herein are true , correct and complete . Subscribed and sworn to before me this _ day of , 20_ ' Notary Public , State of Florida : My Commission Expires : ' Accompanying Documentation . ' NOTICE OF NON-PAYMENT. If one or more "Notice of Non-Payment " or "Notice to Owner" is received by the OWNER, no further payments will be approved until non-payment(s) have been satisfied and a "Lien Waiver" for each "Notice " has been submitted to the OWNER. Upon request, CONTRACTOR shall furnish acceptable evidence that all such claims have been satisfied. The CONTRACTOR may, with consent of Surety and indemnification of the OWNER against any claims, receive payment for work for which there is an outstanding "Notice of Non- Payment" or "Notice to Owner. " **************************************************************************************************** ' CERTIFICATION OF ENGINEER i INSPECTOR : I have checked the estimate against the Contractor's Schedule of Amounts for Contract ' Payments and the notes and reports of my inspections of the project . It is my opinion that this statement of work performed and/or materials supplied is accurate , that the Contractor is observing the requirements of the Contract , and that the Contractor should be paid the amount ' requested above . Dated SIGNATURE Indian River County Public Works ' Approved Date Director Division Head Account No. 00622-Contractor's Application for Payment 00622 - 2 F:\Public Works\Capital Projects\Fourth Street-Old Dixie-USI \CONTRACT DOCUMENTS\00622-Contractor's Application for Payment.doc