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Application For Payment - continued <br />Total Contract Amount: $ 373,094.40 <br />Material <br />3c► C.v- �c <br />Total Amount Earned $ --341742-731-6-5 <br />Suitably Stored on Site, Not Incorporated into Work $ <br />Contract Change Order No. 1, aJ 3 <br />Contract Change Order No. -/` ,j <br />Contract Change Order No. <br />Contractor's Affidavit <br />The undersigned Contractor hereby swears under penalty of perjury that (1) all previous progress payments <br />received from the Owner on account of work performed under the contract referred to above have been applied <br />by the undersigned to discharge in full all obligations of the undersigned incurred in connection with work covered <br />by prior Applications for Payment under said contract, and (2) all materials and equipment incorporated in said <br />Project or otherwise listed in or covered by this Application for Payment are free and clear of all liens, claims, <br />security interests and encumbrances. <br />Percent Complete i oo 20 $ 9 657, FI <br />Percent Complete Joo $ 4/3,16Z4/3 <br />Percent Complete $ L-191-1, 503, ems; <br />GROSS AMOUNT DUE $ <br />LESS D % RETAINAGE $ <br />AMOUNT DUE TO DATE $ I-IL\JCl� <br />LESS PREVIOUS APPLICATION $ �� , ("..)C1 <br />a <br />AMOUNT DUE THIS APPLICATION $ Z t �-M (j , <br />Dated 2)20.4,d, JD <br />COUNTY OF <br />STATE OF <br />Before me on this <br />) SS <br />Central Landscaping Inc. <br />By: <br />( <br />tractor) <br />"CdD <br />(Named Title) <br />day of , 19 _ personally appeared <br />known to me, who being duly sworn, did depose and say that he is the <br />of the Contractor mentioned above; that he executed the above Application for <br />(Office) <br />Payment and Affidavit on behalf of said Contractor; and that all of the statements contained therein are true, <br />correct and complete. <br />My Commission Expires: <br />(Notary Public) <br />The undersigned has checked the Contractor's Application for Payment shown above. Apart of this Application <br />is the Contractor's Affidavit stating that all previous payments to him under this Contract have been applied by him <br />to discharge in full all of his obligations in connection with the work covered by all prior Applications for Payment. <br />In accordance with the Contract, the undersigned approves payment to the Contractor of the Amount Due. <br />Date oc) <br />Page 4 of 4 <br />By <br />SHORT ELLI <br />TT HENDRICKSON INC. <br />LINOL 9808.01 <br />