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40 <br />ob <br />M <br />INDIAN RIVER COUNTY, FLORIDA <br />APPLICATION FOR PAYMENT NO.— <br />PROJECT NO: ACCOUNT <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 />anateriais 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 Paymcnt under said contract, being Applications for 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 />Dated , 2000 <br />(Contractor) <br />(Namc/Titic) <br />COUNTY OF INDIAN RIVER <br />STATE OF FLORIDA <br />Beforc me this _ day of , 2000, personally appeared <br />known to me, who being duly swam, deposes and says that (s)he <br />is the of the CONTRACTOR above mentions; that (s)hc executed <br />the above Application for Payment and statement on behalf of said CONTRACTOR; and <br />that all of the statements contained herein are true, correct and complete. <br />Notary Public <br />My Commission Expires: <br />APPLICATION FOR PAYMENT <br />AP - 1 <br />STATEMENT OF WORK <br />Original Contract Price <br />$ <br />Materials Stored <br />$ <br />Net Change Orders <br />$ <br />(Attach uctailed schedule and paid invoices) <br />Current Contract Price <br />$ <br />Total 'W'ord/Matcrials 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 />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 />anateriais 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 Paymcnt under said contract, being Applications for 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 />Dated , 2000 <br />(Contractor) <br />(Namc/Titic) <br />COUNTY OF INDIAN RIVER <br />STATE OF FLORIDA <br />Beforc me this _ day of , 2000, personally appeared <br />known to me, who being duly swam, deposes and says that (s)he <br />is the of the CONTRACTOR above mentions; that (s)hc executed <br />the above Application for Payment and statement on behalf of said CONTRACTOR; and <br />that all of the statements contained herein are true, correct and complete. <br />Notary Public <br />My Commission Expires: <br />APPLICATION FOR PAYMENT <br />AP - 1 <br />