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• PROJECT NO: -9-622 INDIAN RIVER COUNTY, FLORIDA APPLICATION FOR PAYMENT NO.— ACCOUNT NO: PRO]ECT:BQMD L%ANt] fH'EANFRONT PAR L - CONTRACTOR NAME/ADDRESS:, APPLICATION DA FOR PERIOD ENDING —� The undersigned CONTRACTOR hereby certifies that all items and announts on the face of this application far payment are correct; that all work has been performed and/or materials supplied in full accordance with the terms and conditions of the conntract- Tlie undersigned CONTRACTOR hereby swears under penalty of perjury that (1) all previous progress payments received from the OWNER on account of work performed under the contract referred to above have been applied by the tuideisigned to discharge in full all obligations of die tuidersigned incurred in connection with work covered by prior Applications for Payment under said contract, being Applicationsfor payment numbered 1 through inclusive; and (2) all materials and equipment utcorporated 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 , 1999 (Contractor) BY (Nanic)7 tle) COUNTY OF INDIAN RIVER STATE OF FLORIDA Before me this day of , 1999, personally appeared known to me, who being duly sworn, deposes and says that (s)he is the oftho CONTRACTOR above mentions; tint (s)he executed the above Application for Payment and statement on behalf of said CONTRACTOR; and that all of the statements contained herein are true, correct and complete. Notary Public My Commission Expires:— APPLIC'A"RUN roc PAYMENT AP - 1 s'rATCMENT OF WORK Original Contract Price Materials Stoted S_ Net Change Orders S (Attach detailed schedule and paid invoices) Current Contract Price S Total Word/Materials to Date $ Work to Date: Less 10% Retainage $ Under Original Contract $ Sulo Total $ Under Change Order $ Less Prior payments S _ Percent of Work Completed to DateQ BALANCE DUE THIS PAYMENT S The undersigned CONTRACTOR hereby certifies that all items and announts on the face of this application far payment are correct; that all work has been performed and/or materials supplied in full accordance with the terms and conditions of the conntract- Tlie undersigned CONTRACTOR hereby swears under penalty of perjury that (1) all previous progress payments received from the OWNER on account of work performed under the contract referred to above have been applied by the tuideisigned to discharge in full all obligations of die tuidersigned incurred in connection with work covered by prior Applications for Payment under said contract, being Applicationsfor payment numbered 1 through inclusive; and (2) all materials and equipment utcorporated 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 , 1999 (Contractor) BY (Nanic)7 tle) COUNTY OF INDIAN RIVER STATE OF FLORIDA Before me this day of , 1999, personally appeared known to me, who being duly sworn, deposes and says that (s)he is the oftho CONTRACTOR above mentions; tint (s)he executed the above Application for Payment and statement on behalf of said CONTRACTOR; and that all of the statements contained herein are true, correct and complete. Notary Public My Commission Expires:— APPLIC'A"RUN roc PAYMENT AP - 1