Attachment_H-Cert_Disb_of_Prev_Periodic_Pymt_to_Subs.pdf
PDF 150 KB Posted
- Solicitation number
- 26-139
- Issued by
- Citrus County, Florida
About this file
This is a Certification of Disbursement of Previous Periodic Payment to Subcontractors form required by the Florida Department of Transportation under Florida Statutes Section 337.11(11) for construction contracts in the state of Florida. The form must be completed and submitted by the prime contractor for each contract to certify that all subcontractors, material suppliers, equipment providers, and service providers have received their proportionate share of periodic payments made by the Department for work, materials, equipment, and services incorporated into the project or stockpiled at the project site. The certification must be signed by an officer or director of the contractor with authority to bind the company and notarized. To prevent delays in monthly payment processing, the completed certification must be submitted to the Project Engineer no later than the Friday preceding the monthly estimate cutoff date, which generally falls on the third Sunday of each month.
The form requires the contractor to list any subcontractors that have not received their pro rata share of payments, along with the date of exception, and to attach copies of notifications sent to those subcontractors explaining the good cause for non-payment. A separate certification is required for each contract. The form explicitly warns that false statements or omissions in connection with the certification may result in suspension, revocation, or denial of bidding qualification, a determination of non-responsibility, and civil and criminal penalties under applicable Federal and State law. The form can be submitted with or without digital signatures and requires notarization with either personal identification or produced identification documentation.
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Text version
List the subcontractors which have not been paid the proportionate share of payments received by the contractor and the date listed as exception.
To be signed by an officer or director of the Contractor with the authority to bind the Contractor and notarized.
To avoid delay in payment, certification must be submitted to the Project Engineer no later than the Friday before the monthly estimate cutoff date (generally the 3rd Sunday of the month).
County of Sworn to (or affirmed) and subscribed before me, by means of physical presence or online notarization, this
DATE
CONTRACT NO.FIN PROJ. I.D.
, prime contractor for the above referenced contract, hereby certifies that all subcontractors, except for those noted below, having interest in this contract have received their pro rata share of all previous periodic payments made to date by the Department for all work, materials and equipment furnished under the contract. The term "subcontractor", as used herein, shall also include persons or firms furnishing materials, services or equipment incorporated into the work or stockpiled in the vicinity of the project for which partial payment has been made by the Department and work done under equipment-rental agreements.
EXCEPTION:
The following subcontractors have not been paid and a copy of the notification sent to each, explaining the good cause why payment has not been made, is attached to this form:
Subcontractor name
Street Address
City State Zip
Subcontractor name
Street Address
City State Zip
By
Title
State of Florida day of , (year), by
(Print name of person signing Certification)
Notary Public
Personally Known OR Produced Identification Type of Identification Produced
Instructions:
Attach copy of the notification good cause sent to each applicable subcontractor.
2.
3. A separate certification is required for each contract.
4.
5.
TO RELEASE MONTHLY PAYMENT FOR
Commission Expires
1.
Contractor
A false statement or omission made in connection with this certification is sufficient cause for suspension, revocation, or denial of qualification to bid, and a determination of non-responsibility, and may subject the person and/or entity making the false statement to any and all civil and criminal penalties available pursuant to applicable Federal and State Law.
STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION
CONSTRUCTION
700-010-38
1/17CERTIFICATION
DISBURSEMENT OF PREVIOUS PERIODIC PAYMENT TO SUBCONTRACTORS
(As required by Florida Transportation Code, Section 337.11, Subsection (11), F.S.)
, not required when digital
| Subcontractor name: |
| Subcontractor name_2: |
| Street Address: |
| Street Address_2: |
| City State Zip: |
| City State Zip_2: |
| day: |
| Print name of person signing Certification: |
| Commission Expires: |
| Title: |
| DATE: |
| CONTRACT_NO: |
| TEXT1: |
| MONTH: |
| YEAR: |
| TYPE_OF_ID: |
| PERSONALLY_KNOWN: Off |
| PRODUCED_ID: Off |
| NOTARY_COUNTY: |
| VENDOR_NAME: |
| Signed by "Contractor Name": |
| FINANCIAL_PROJECT_ID 2: |
| FINANCIAL_PROJECT_ID 1: |
| FINANCILA_PROJECT_ID 3: |
| FINANCIAL_PROJECT_ID 4: |
| CheckBox1: Off |
| CheckBox2: Off |
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