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SECTION 00622 - Contractor ' s Application for Payment <br /> Quail Creek Subdivision <br /> Application for Payment No . <br /> For Work Accomplished through the period of through <br /> To : Indian River County ( OWNER ) <br /> From : ( CONTRACTOR ) <br /> Bid : 2011012 <br /> Project : 2004020196 -45291 <br /> 1 ) Attach detailed schedule and copies of all paid invoices . <br /> 1 . Original Contract Price : $ <br /> 2 . Net change by Change Orders and Written Amendments ( + or - ) : $ <br /> 3 . Current Contract Price ( 1 plus 2 ) : <br /> 4 . Total completed and stored to date : $ <br /> 5 . Retainage ( per Agreement ) : <br /> of completed Work : $ <br /> % of retainage : $ <br /> Total Retainage : $ <br /> 6 . Total completed and stored to date less retainage (4 minus 5 ) : $ <br /> 7 . Less previous Application for Payments : $ <br /> 8 . DUE THIS APPLICATION 6 MINUS 7 ) : $ <br /> * * Attach detailed schedule of materials and copies of all invoices with lien releases <br /> CONTRACTOR ' S CERTIFICATION : <br /> UNDER PENALTY OF PERJURY , the undersigned CONTRACTOR certifies that ( 1 ) the labor <br /> and materials listed on this request for payment have been used in the construction of this Work <br />; ( 2 ) <br /> payment received from the last pay request has been used to make payments to all subcontractors <br /> , <br /> laborers , material men and suppliers except as listed on Attachment A , below ; ( 3 ) title of <br /> all Work , <br /> materials and equipment incorporated in said Work or otherwise listed in or covered by this <br /> Application for Payment will pass to OWNER at time of payment free and clear of all Liens , <br /> security <br /> interests and encumbrances ( except such as are covered by a Bond acceptable to OWNER <br /> indemnifying OWNER against any such Lien , security interest or encumbrance ) ; ( 4 ) all Work <br /> covered by this Application for Payment is in accordance with the Contract Documents and not <br /> defective ; and ( 5 ) If this Periodic Estimate is for a Final Payment to project or improvement <br />, I further <br /> certify that all persons doing work upon or furnishing materials or supplies for this project or <br /> improvement under this foregoing contract have been paid in full , and that all taxes imposed by <br /> Chapter 212 Florida Statutes , ( Sales and Use Tax Act , as Amended ) have been paid and <br /> discharged , and that I have no claims against the OWNER . <br /> Attached to or submitted with this form are : <br /> 1 . Signed release of lien forms ( partial or final as applicable ) from all subcontractors <br /> , laborers , <br /> material men and suppliers except as listed on Attachment A , together with an explanation <br /> as to why any release of lien form is not included ; <br /> 00622 - 1 <br /> F :\Engineering\Land Development Permits\Quail Creek PD\Bid-Contract Documents\00622 - Contractor's Application for Payment - new template <br />03- 10 rev.doc Rev . 05/01 <br />