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Page 2 of 6 <br /> Attached to or submitted with this form are . <br /> 1 . Signed release of lien forms (partial or final as applicable) from all subcontractors , laborers , <br /> materialmen and suppliers except as listed on Attachment A, together with an explanation as <br /> to why any release of lien form is not included ; <br /> 2 . Updated Construction Schedule per Specification Section 01310 , and <br /> Dated By: <br /> (CONTRACTOR — must be signed by <br /> an Officer of the Corporation ) <br /> Print Name and Title <br /> STATE OF FLORIDA <br /> COUNTY OF INDIAN RIVER <br /> Before me , a Notary Public, duly commissioned , qualified , and acting , personally appeared <br /> who being by me first duly sworn upon oath , says that he/she is the <br /> of the CONTRACTOR mentioned above and that he/she has been duly <br /> authorized to act on behalf of it, and that he/she executed the above Contractor's Application for <br /> Payment and Contractor's Certification statement on behalf of said CONTRACTOR, and that all of <br /> the statements contained herein are true , correct, and complete . Subscribed and sworn to before <br /> me this day of <br /> is personally known to me or has produced <br /> as identification . <br /> NOTARY PUBLIC : <br /> (SEAL) Printed name : <br /> Commission No . . <br /> Commission Expiration : <br /> [The remainder of this page was left blank intentionally] <br /> 00622 - Contractor's Application for Payment - 03- 10 rev.doc <br /> - 00622 - 2 <br /> FAPublic Works\ENGINEERING DIVISION PROJECTSt0545-66Th Ave SR60 to 57th St (Arcadis)Wdmim\Bid Documents\00622 - Contractor's Application for Payment - 03-10 <br /> rev.doc <br /> Rev. 05/01 <br /> F <br />