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Please do separate check <br />Dated: 01/23/19 By: <br />STATE OF FLORIDA <br />COUNTY OF INDIAN RIVER <br />(CONTRACTOR - must be signed <br />Timothy Rose, President <br />Print Name and Title <br />Before me, a Notary Public, duly commissioned, qualified, and acting, personally appeared <br />Timothy Rose, who being by me first duly swom upon oath, says that he/she is the President of <br />the CONTRACTOR mentioned above and that he/she has been duly authorized to act on behalf <br />of it, and that he/she executed the above Contractor's Application for Payment and Contractor's <br />Certification statement on behalf of said CONTRACTOR; and that all of the statements <br />contained herein are true, correct, and complete. Subscribed and sworn to before me this 23rd <br />day of January, 2019 <br />Timothy Rose is personally known to me or has produced as identification. <br />cin-nc. p i i WEST <br />OE Oi�V'L'3 E r' <br />IY COMMISSION # F 9U4573 <br />EXPIRES: Oamhe 03, 2019 <br />Please remit payment to: <br />NOTARY PUBLIC: <br />Printed name: Deborah West <br />Contractor's Name: Timothy Rose Contracting <br />Address: 1360 SW Old Dixie Hwy Suite 106 <br />Vero Beach FL 32962 <br />Commission No: FF904578 <br />Commission Expiration:. 10.03.19 <br />[The remainder of this page was left blank intentionally] <br />00622-2 <br />32 <br />