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Page 2 of 5 <br />2. Updated Construction Schedule per Specification Section 01310. <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, who being <br />by me first duly sworn upon oath, says that he/she is the of the <br />CONTRACTOR mentioned above and that he/she has been duly authorized to act on behalf of it, and <br />that he/she executed the above Contractor's Application for Payment and Contractor's Certification <br />statement on behalf of said CONTRACTOR; and that all of the statements contained herein are true, <br />correct, and complete. Subscribed and sworn to before 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 />Contractor's Application for Partial Payment - 06-09 rev - 00622 - 2 <br />FAlcublic Works\ENGINEERING DIVISION PROJECTS\2022 4th St Culvert Replacement at 90th Ave\1-Admin\Bids\Bid Documents\DIV 0 3 Contract Forms - 20201118.docx <br />