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+f <br />U13 <br />i <br />INDIAN RIVER COUNTY, FLORIDA <br />as r <br />APPLICATION FOR PAYMENT NO.— <br />PROJECT NO: 2621B ACCOUNT NO:. <br />I <br />PROJECT: `t' BASSr.n►rrcrsirnynnuu rrurrau�lVr;MFretTQ <br />CONTRACTOR' NAME/ADDRESS: - <br />APPLICATION DATE: FOR PERIOD ENDING <br />The undersigned CONTRACTOR hereby certifies that all items and amounts on the face <br />of this application for payment are correct; that all work has been performed and/or <br />materials supplied in full accordance with the terms and conditions of the contract. <br />The undersigned CONTRACTOR hereby swears under penalty of perjury that (1) all <br />previous progress payments received from the OWNER on account of work performed <br />under the contract referred to above have been applied by the undersigned to discharge in <br />full all obligations of the undersigned incurred in connection with work covered by prior <br />Applications for Payment under said contract, being Applications Far Payment numbered <br />I through inclusive; and (2) all materials and equipment incorporated in said project <br />or otherwise listed in or covered by this Application for Payment are Free and clear of all <br />liens, claims, security interests and encumbrances. <br />i Dated 2000 <br />-. <br />{Contractor} <br />{ <br />CA Y; <br />l (NamerriIIe) <br />COUNTY OF INDIAN RIVER <br />l STATE OF FLORIDA <br />Before me this — day of ?.000. personally appeared <br />t , known to me, who being duly sworn, deposes and says that (s)he <br />is the of the CONTRACTOR above mentiorts; that (s)he executed <br />the above Application for Payment and statement on behalf of said CONrRACI'OR; and <br />( that all of the statements contained herein are true, correct and complete. <br />4 Mowry Public <br />My( 'wimlism)lr F'tPorus— <br />V <br />l APNt.t£'AT1rrN FOR PAYME'N'T <br />L AP - t <br />STATEMENT OF WORK <br />Original Contract Price <br />$ <br />Materials Stored <br />$ <br />Net Change Orders <br />(Attach derailed schedule and paid invoices) <br />Current Contract Price <br />$ <br />Total Word/Materials to Date <br />$ <br />Work to Date: <br />Less 10% Retainage <br />$ <br />Under Original Contract <br />$ <br />Sub Total <br />$ <br />Under Change Order <br />$ <br />Less Prior Payments <br />$ <br />Percent of Work Completed to Date— <br />----% <br />BALANCE DUE THIS PAYMENT <br />$_. <br />The undersigned CONTRACTOR hereby certifies that all items and amounts on the face <br />of this application for payment are correct; that all work has been performed and/or <br />materials supplied in full accordance with the terms and conditions of the contract. <br />The undersigned CONTRACTOR hereby swears under penalty of perjury that (1) all <br />previous progress payments received from the OWNER on account of work performed <br />under the contract referred to above have been applied by the undersigned to discharge in <br />full all obligations of the undersigned incurred in connection with work covered by prior <br />Applications for Payment under said contract, being Applications Far Payment numbered <br />I through inclusive; and (2) all materials and equipment incorporated in said project <br />or otherwise listed in or covered by this Application for Payment are Free and clear of all <br />liens, claims, security interests and encumbrances. <br />i Dated 2000 <br />-. <br />{Contractor} <br />{ <br />CA Y; <br />l (NamerriIIe) <br />COUNTY OF INDIAN RIVER <br />l STATE OF FLORIDA <br />Before me this — day of ?.000. personally appeared <br />t , known to me, who being duly sworn, deposes and says that (s)he <br />is the of the CONTRACTOR above mentiorts; that (s)he executed <br />the above Application for Payment and statement on behalf of said CONrRACI'OR; and <br />( that all of the statements contained herein are true, correct and complete. <br />4 Mowry Public <br />My( 'wimlism)lr F'tPorus— <br />V <br />l APNt.t£'AT1rrN FOR PAYME'N'T <br />L AP - t <br />