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114, 4 <br /> Page 2 of 6 <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 <br /> 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 , 20 <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 /> F :\Public Works\ENGINEERING DIVISION PROJECTS\98106-66th Ave Ph 2 4th St to 16th SMdmim\bid documents\00622 - Contractor's Application for Payment <br /> - 03- 10 rev .doc <br /> Rev. 05/01 <br /> �, Till <br />