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.A, JEL- <br /> Van Fleet Water Production Facility Improvements BVP 13-196 <br /> EXHIBIT 9 <br /> GENERAL CONTRACTOR APPLICATION AND CERTIFICATE FOR PAYMENT <br /> TO: POLK COUNTY BOARD OF COUNTY <br /> COMMISSIONERS Application Date: Page of pages <br /> Application No.: Contract No.: <br /> CONTRACTOR: <br /> PO No <br /> ADDRESS: <br /> PROJECT: <br /> Period From: To: <br /> CHANGE ORDER SUMMARY Application is made for Payment,as shown below,in connection with the Contract. <br /> Change Orders approved this month Continuation Sheet is attached. <br /> Number Date Approved ADDITION DEDUCTION <br /> 1. ORIGINAL CONTRACT SUM <br /> 2. Net change by Change Orders $ <br /> TOTAL $ $ 3. CONTRACT SUM TO DATE(Line 1+/-2) $ <br /> Approved in 2revious months 4. TOTAL COMPLETED&STORED TO DATE(Col.G) <br /> Number Date Approved 5. RETAINAGE <br /> a. 10 %of Completed work <br /> (Column D+E) <br /> b. 10 %of Stored Material <br /> TOTALS $ $ (Column F) <br /> Net change by Change Orders $ Total Retainage(Line 5a+5b) $ <br /> 6. TOTAL EARNED LESS RETAINAGE $ <br /> The undersigned Contractor certifies that to the best of the Contractor's knowledge, (Line 4 less Line 5 Total) <br /> information and belief the Work covered by this Application for Payment has been completed 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT <br /> in accordance with the Contract Documents,that all amounts have been paid by the (Line 6 from previous application) <br /> Contractor for Work for which previous Certificates for Payment were issued and payments 8. CURRENT PAYMENT DUE $ <br /> received from the County,and that current payment shown herein is now due. 9. BALANCE TO FINISH,WITH RETAINAGE $ <br /> (Line 3 less Line 6) <br /> CONTRACTOR: <br /> County <br /> State of. of <br /> day <br /> B,. Date Subscribed and swom to before me this _ of <br /> Payment of the above AMOUNT DUE THIS APPLICATION is recommended. <br /> Notary Public: <br /> My Commission expires: <br /> Professional <br /> Payment of the above AMOUNT DUE THIS APPLICATION is <br /> recommended. <br /> COUNTY: By: <br /> _ 48 <br /> coS <br />