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Page 3 of 5 <br />SURETY'S CONSENT OF PAYMENT TO CONTRACTOR: <br />The Surety, <br />,a <br />corporation, in accordance with Public Construction Bond Number , hereby <br />consents to payment by the OWNER to the CONTRACTOR, for the amounts specified in <br />this CONTRACTOR's APPLICATION FOR PAYMENT. <br />TO BE EXECUTED BY CORPORATE SURETY: <br />Attest: <br />Secretary Corporate Surety <br />STATE OF FLORIDA <br />COUNTY OF INDIAN RIVER <br />Business Address <br />BY: <br />Print Name: <br />Title: <br />(Affix Corporate SEAL) <br />Before me, a Notary Public, duly commissioned, qualified, and acting, personally appeared <br />, to me well known or who produced <br />as identification, who being by me first duly sworn <br />upon oath, says that he/she is the for <br />and that he/she has been authorized by it to approve payment <br />by the OWNER to the CONTRACTOR of the foregoing Contractor's Application for <br />Payment. Subscribed and sworn to before me this day of <br />, 20 <br />Notary Public, State of <br />My Commission Expires: <br />**************************************************************************************************** <br />[The remainder of this page was left blank intentionally] <br />00622 - Contractor's Application for Payment - 03-10 rev <br />00622 - 3 <br />F:\Public Works\ENGINEERING DIVISION PROJECTS\1628-85th Street_96th Ave to 101st Ave_ Roadway Improvements\1-Admin\Bids\Bid Documents\Master Contract <br />Documents \00622 - Contractors Application for Payment - 03-10 rev.doc Rev. 05/01 <br />