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SECTION 00622 we Contractor's Application for Payment Old Dixie Highway Sidewalk Improvements from 8th St . to S . R. 60 Application for Payment No . For Work Accomplished through the period of through To : Indian River County (OWNER) From : I (CONTRACTOR) Bid : 2012052 Project: 1102 1 ) Attach detailed schedule and copies of all paid invoices. 1 . Original Contract Price : $ 2 . Net change by Change Orders and Written Amendments (+ or 3 . Current Contract Price ( 1 plus 2) : 4 . Total completed and stored to date : $ 5 . Retainage ( per Agreement) : of completed Work: $ of retainage : $ Total Retainage : $ 6 . Total completed and stored to date less retainage (4 minus 5) : $ 7 . Less previous Application for Payments : $ 8 . DUE THIS APPLICATION 6 MINUS 7) : $ CONTRACTOR'S CERTIFICATION : UNDER PENALTY OF PERJURY, the undersigned CONTRACTOR certifies that ( 1 ) the labor and materials listed on this request for payment have been used in the construction of this Work; (2) payment received from the last pay request has been used to make payments to all subcontractors , laborers , materialmen and suppliers except as listed on Attachment A , below; (3) title of all Work , materials and equipment incorporated in said Work or otherwise listed in or covered by this Application for Payment will pass to OWNER at time of payment free and clear of all Liens , security interests and encumbrances (except such as are covered by a Bond acceptable to OWNER indemnifying OWNER against any such Lien , security interest or encumbrance) ; (4) all Work covered by this Application for Payment is in accordance with the Contract Documents and not defective ; and (5) If this Periodic Estimate is for a Final Payment to project or improvement, I further certify that all persons doing work upon or furnishing materials or supplies for this project or improvement under this foregoing contract have been paid in full , and that all taxes imposed by Chapter 212 Florida Statutes , (Sales and Use Tax Act , as Amended) have been paid and discharged , and that I have no claims against the OWNER . Attached to or submitted with this form are : 1 . Signed release of lien forms (partial or final as applicable) from all subcontractors , laborers , materialmen and suppliers except as listed on Attachment A, together with an explanation as to why any release of lien form is not included ; 00622 - Contractor's Application for Payment - 03A0 rev.doc 00622 - 1 F:\Public Works\ENGINEERING DIVISION PROJECTS\1102-Old Dixie Hwy Swk 8th St to SR 60-LAP\Admim\bid documents\Master Contract Documents100622 - Contractor's Application for Payment - 03-10 rev.doc Rev. 05101 i