Attachment_I-Cert_Disb_of_Prev_Periodic_Pymt_to_Subs.pdf

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

ATTACHMENT "I"