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CONTRACTOR'S CERTIFICATION: <br /> UNDER PENALTY OF PERJURY, the undersigned CONTRACTOR certifies that all <br /> previous progress payments received on account of the Work have been applied on account to <br /> discharge CONTRACTOR's specific legitimate obligations associated with prior Applications for <br /> Payment. This certification includes, but is not limited to the following statements of fact: (1) <br /> the labor and materials listed on this request for payment have been used in the construction of <br /> this Work; (2) payment received from the last pay request has been used to make payments to <br /> all subcontractors, laborers, materialmen and suppliers except as listed on Attachment A, <br /> below; (3) title of all Work, materials and equipment incorporated in said Work or otherwise <br /> listed in or covered by this Application for Payment will pass to OWNER at time of payment free <br /> and clear of all Liens, security interests and encumbrances (except such as are covered by a <br /> Bond acceptable to OWNER indemnifying OWNER against any such Lien, security interest or <br /> encumbrance); (4) all Work covered by this Application for Payment is in accordance with the <br /> Contract Documents and not defective; and (5) If this Periodic Estimate is for a Final Payment <br /> to project or improvement, I further certify that all persons doing work upon or furnishing <br /> materials or supplies for this project or improvement under this foregoing contract have been <br /> paid in full, and that all taxes imposed by Chapter 212 Florida Statutes, (Sales and Use Tax <br /> Act, as Amended) have been paid and discharged, and that I have no claims against 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, materialmen and suppliers except as listed on Attachment A, together with an <br /> explanation as to why any release of lien form is not included; <br /> 2. Progress Record Drawings per Specification Sections 01330 and 01720. <br /> ,NOW Under oath, I swear that the foregoing statements are true. <br /> Dated: By: <br /> (CONTRACT —must be signed by <br /> an Officer of the Corporation) <br /> Print Name and Title <br /> STATE OF FLORIDA- COUNTY OF hJe <br /> Before me, Notary Public, duly commissioned, qualified, and acting, personally appeared <br /> 1 i1R tOMQ , 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 <br /> duly authorized to act on behalf of it, and that -Wshe executed the above Contractor's <br /> Application for Payment and Contractor's Certification statement on behalf of said <br /> CONTRACTOR; and that all of the statements contained herein are true, correct, and complete. <br /> Subscribed and sworn to before me this _A_a day of �'-2C\�� , 20_L/2,. <br /> ,1A ispersonally known to me or has produced <br /> as IdentifiIcaaII <br /> A._6 I UNE _ <br /> NOTARY PUBLIC NOTARY PUBLIC: <br /> & <br /> STATE OF FLORIDA <br /> � Comm#DD965486 <br /> (SE AL �,yExpires 2/24/2014 Printed name: <br /> Commission No.: Commission Expiration: <br /> Last Revised 2-16-2012 Application for Payment Final <br /> 00622-2 3 7 <br /> L:\Close Projects-Current\586-Egret Marsh\Pay Applications\Final Pay AppWpplication for Payment Final.doc Rev.05/01 <br />