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Dated By: <br />STATE OF FLORIDA <br />COUNTY OF INDIAN RIVER <br />(CONTRACTOR — must be signed by <br />an Officer of the Corporation) <br />Print Name and Title <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 , 20 <br />is personally known to me or has produced <br />as identification. <br />(SEAL) <br />NOTARY PUBLIC: <br />Printed name. <br />Commission No.: <br />Commission Expiration: <br />**************************************************************************************************** <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\1302-IR Blvd Resurfacing (SCOP) US1 to 17th St\Admim\bid documents\00622 - Contractors Application for Payment - 03-10 <br />rev.doc Rev. 05/01 <br />