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Page 2 of 5 <br />2. Updated Construction Schedule per Specification Section 01310, and <br />Dated By: <br />(CONTRACTOR — must be signed by <br />an Officer of the Corporation) <br />Print Name and Title <br />STATE OF FLORIDA <br />COUNTY OF INDIAN RIVER <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 />(SEAL) <br />Please remit payment to: <br />Contractor's Name: <br />Address: <br />is personally known to me or has produced <br />as identification. <br />NOTARY PUBLIC: <br />Printed name: <br />Commission No.: <br />Commission Expiration: <br />[The remainder of this page was left blank intentionally] <br />00622 - Contractor's Application for Payment - 03-10 rev <br />00622-2 <br />F:\PublicWorks\ENGINEERING DIVISION PROJECTS\1324 58th Ave Resurfacing IN. of 26th Sl to N. of 57th St)\1-Admin\Bid documents\Master Contract Documents\00622 - <br />Contractor's Application for Payment - 03-10 rev.doc Rev. 05/01 <br />