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INDIAN RIVER COUNTY, FLORIDA APPLICATION FOR PAYMENT NO. PROJECT NO: ACCOUNT PROJECT: CONTRACTOR NAME/ADDRESS: APPLICATION DATE: FOR PERIOD ENDING STATEMENT OF WORK. Original Contract Price $ _ Materials Stored $ Not Change Orders $ (Attach detailed schedule and paid Invoices) Current Contract Price Total WordfMaterials to Date $ Work to Date: Less 46% Retainage $ Under Original Contract $ Sub Total g Under Change Order $ _ Less Prior Payments $ Percent of Work Completed to Date % BALANCE DUE THIS PAYME=NT $ Contractors Certification The undersigned CONTRACTOR hereby certifies that all items and amounts on the Face of this application for payment are correct; that all work has been performed and/or materials supplied In full accordance will) the terms and conditions of the contract. The undersigned CONTRACTOR hereby swears under penalty of perjury that (3) all previous progress payments received from the OWNER on account of work performed under the contract referred to above have been applied by the undersigned to discharge in full all nhlinntinnc of she undersigned incurred in connection with work covered by prior Applications for Payment under said contract, being Applications for Payment numbered 1 through inclusive; and (2) all materials and equipment incorporated in said project or otherwise listed In or covered by this Application for Payment are free and clear of all liens, claims, security interests and encumbrances. Dated-- , ig (Contractor) BY: (NamefTitie) COUNTY OF INDIAN RIVER STATE OF FLORIDA Bafore ma this day of , 19— ;personally appeared ~known to me, who being duly sworn, deposes and says that (s)he is the of the CONTRACTOR above mentions; that (s)he executed the above Application for Payment and statement on behalf of said CONTRACTOR; and that all of the statements contained hereln are true, correct and complete. Notary Public My Commission Expires Ct TRAe-r AP