Attachment_I-Cert_Disb_of_Prev_Periodic_Pymt_to_Subs.pdf
PDF 194 KB Posted
- Solicitation number
- ITB 25-111
- Issued by
- Citrus County, Florida
About this file
This is a Certification of Disbursement of Previous Periodic Payment to Subcontractors form required by the State of Florida Department of Transportation for construction projects under Florida Transportation Code Section 337.11. The form serves as a monthly certification whereby prime contractors attest that all subcontractors, material suppliers, and equipment rental providers have received their proportionate share of payments received from the Department, or identify exceptions with supporting documentation of good cause explanations. The certification must be submitted to the Project Engineer no later than the Friday before the monthly estimate cutoff date (generally the third Sunday of each month) to avoid delays in payment processing. The document requires certification by an authorized officer or director of the contractor and must be notarized, either through physical presence or online notarization, with the notary public indicating whether the signatory was personally known or presented identification.
The form applies to the Citrus County Small County Outreach Program road resurfacing project for S. Apopka Avenue (ITB 25-111), which is funded entirely through a Florida Department of Transportation SCOP grant with Financial Project Number 449062-1-54-01 and a County budget of approximately $1,630,270. The form requires contractors to list any subcontractors who have not received their proportionate payment share, provide the dates of non-payment exceptions, and attach copies of notifications explaining the good cause for non-payment to each affected subcontractor. False statements or omissions on this certification expose the contractor and responsible individuals to suspension or revocation of qualification to bid, determination of non-responsibility, and civil and criminal penalties under applicable Federal and State law. A separate certification is required for each contract, and the document includes fields for contractor name, contract number, financial project identification numbers, month and year of the certification, and details of all subcontractors subject to the certification.
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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
ATTACHMENT "I"
| 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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