Laserfiche WebLink
• <br />1) <br />MPROJECT: —_ <br />CONTRACTOR NAME/ADDRESS: "'---_ <br />APPLICATION DA <br />FOR PERIOD ENDIN <br />STATEMENT OF WORK <br />Original Contract Price $_ Materials Stored $_ <br />Net Change Orders $ (Attach detailed schedule and paid invoices) <br />Current Contract Price $� Total Word/Materials to Date $--- <br />Work <br />_ _-_.Work to Dale: Less 10% Retainage $ <br />Under Original Contract $ Sub Total $ <br />Under Change Order $ Less Prior Payments $ <br />Percent of Work Completed to Date % <br />BALANCE DUE THIS PAYMENT $ <br />Contractors Certification <br />The undersigned CONTRACTOR hereby certifies that all items and amounts on the face of this <br />application for payment are correct; that all work has been performed and/or materials supplied in full <br />accordance with the terms and conditions of the contract. <br />The undersigned CONTRACTOR hereby swears under penalty of perjury that (1) all previous <br />progress payments received from the OWNER on account of work performed under the contract <br />referred to above have been applied by the undersigned to discharge in full all obligations of the <br />undersigned incurred in connection with work covered by prior Applications for Payment under said <br />contract, being Applications for Payment numbered 1 through inclusive; and (2) all materials <br />and equipment Incorporated in said project or otherwise listed in or covered by this Application for <br />Payment are free and clear of all liens, claims, security interests and encumbrances. <br />Dated , 2000 <br />BY: <br />COUNTY OF INDIAN RIVER <br />STATE OF FLORIDA <br />(Contractor) <br />(Name/Title) <br />Before me this _ day of 2000, personally appeared <br />, known to me, who being duly sworn, deposes and says that (s)he is the <br />of the CONTRACTOR above mentions; that (s)he executed the above Application for <br />Payment and statement on behalf of said CONTRACTOR; and that all of the statements contained <br />herein are true, correct and complete. <br />Notary Public <br />My Commission Expires <br />CONTRACT <br />AP - 2 <br />