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STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION <br />CERTIFICATION <br />DISBURSEMENT OF PREVIOUS PERIODIC PAYMENT TO SUBCONTRACTORS <br />(As required by Florida Transportation Code, Section 337.11, Subsection (11), F.S.) <br />FIN PROJ. I.D. 431728-1-58-01 <br />DATE December 20, 2016 <br />700*10.38 <br />CONSTRUCTION <br />/ono <br />CONTRACT NO. ART -06 <br />TO RELEASE MONTHLY PAYMENT FOR Retainage <br />KERNS CONSTRUCTION & PROPERTY MANAGEMENT, INC. <br />prime contractor <br />for the above referenced contract, hereby certifies that all subcontractors, except for those noted below, having interest in <br />this contract have received their pro rata share of all previous periodic payments made to date by the Department for all <br />work, materials and equipment furnished under the contract. The term "subcontractor", as used herein, shall also include <br />persons or firms furnishing materials, services or equipment incorporated into the work or stockpiled In the vicinity of the <br />project for which partial payment has been made by the Department and work done under equipment -rental agreements. <br />EXCEPTION: <br />The following subcontractors have not been paid and a copy of the notification sent to each, explaining the good cause <br />why payment has not been made, is attached to this form: <br />Subcontractor name <br />Street Address <br />City State Zip <br />State of Florida <br />County of <br />Sworn to and subscribbd before me this OJ6M day <br />of��� , by�� <br />My COMMISSION 0 FF923607 <br />EXPIRES October 31 2019 <br />Personally Known -k OR Produced Identification <br />Type of Identification Produced <br />Instructions: <br />Subcontractor name <br />Street Address <br />City State Zip <br />A false statement or omission made in connection with this <br />certification is sufficient cause for suspension, revocation, <br />or denial of qualification to bid, and a determination of non - <br />responsibility, and may subject the person andfor entity <br />making the false statement to any and all civil and criminal <br />penalties available pursuant to applicable Federal and State <br />Law. <br />Kerns Construction & Property Managment, Inc. <br />---� Contractor <br />By <br />Executive Vice President <br />Title <br />1. Attach copy of the notification good cause sent to each applicable subcontractor. <br />2. List the subcontractors which have not been paid the proportionate share of payments received <br />by the contractor and the date ist�f' ed as exception. <br />3. A separate certification is required for each contract. <br />4. To be signed by an officer or director—o ate on or with the authority to bind the Contractor and notarized. <br />5. To avoid delay in payment, certification must be submitted to the Project Engineer no later than the Friday <br />before the monthly estimate cutoff date (generally the 3rd Sunday of the month). <br />P86 <br />