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Dated (CONTRACTOR) By: State of County of Subscribed and sworn to before me this day of Notary Public My Commission expires: 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 ARCHITECT OR CONSULTING ENGINEER (WHERE APPLICABLE) : I certify that I have checked and verify the above and foregoing Periodic Estimate for Partial Payment; that to the best of my knowledge and belief it is a true and correct statement of the work performed and/or material supplied by the Contractor. Dated (ARCHITECT / ENGINEER) SIGNATURE CERTIFICATION OF ENGINEER / 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 j above. Dated (ARCHITECT / ENGINEER) SIGNATURE Accompanying Documentation : y [The Remainder of Pape Intentional Left Blank 00622 - Contractor's Application for Payment 2006079.doc 00622 - 2 F:\Public Works\Capital Projects\SR AIA & CR 510 Turn Lanes_IRC-9701\1310 DOCUMENTS 2006079\00622 - Contractors Application for Payment 2006079.doc Rev. 05101