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 under Florida Transportation Code, Section 337.11, Subsection (11), F.S., for use on the Citrus County road resurfacing project ITB 25-111. The form functions as a monthly certification document that the prime contractor must submit to the Project Engineer no later than the Friday before the monthly estimate cutoff date (generally the third Sunday of each month) to release monthly payment. The contractor must certify that all subcontractors, including material suppliers and equipment rental firms, have received their pro rata share of all previous periodic payments made by the Department, or list exceptions identifying subcontractors that have not been paid along with the dates and good cause explanations for non-payment. The certification must be signed by a contractor officer or director with binding authority and notarized, with separate certifications required for each contract.
The form requires the contractor to provide detailed information including the contract number, financial project identification number, month and year of the certification, and complete subcontractor details (name, street address, city, state, and zip code) for any exceptions. Attachments must include copies of notifications sent to unpaid subcontractors explaining the good cause for payment withholding. False statements or omissions made in connection with the certification are grounds for suspension, revocation, or denial of bid qualification, determination of non-responsibility, and civil and criminal penalties under applicable Federal and State law. Notarization must confirm either personal knowledge of the signer or identification verification, with the notary's county of commission and expiration date recorded on the form.
View the file
Other files
Show all 19
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 |
File details come from the government source that posted it. Updated .