SEMINOLE COUNTY BOARD OF COUNTY COMMISSIONERS

CONSTRUCTION FORMS

EXHIBIT TO THE AGREEMENT

TO BE PROVIDED TO THE CONTRACTOR WITH THE AGREEMENT

Application for Payment ..................................................................................................... C-01

Continuation Sheet for Application for Payment ................................................................. C-01 (2)

Change Order Form ............................................................................................................ C-02

Shop Drawing Submittals ................................................................................................... C-03

Authorized Field Change (AFC) ......................................................................................... C-04

Certificate of Substantial Completion ................................................................................ C-05

Certificate of Final Completion .......................................................................................... C-06

Contractor’s Release .......................................................................................................... C-07

Contractor’s Waiver of Lien (Partial) ................................................................................. C-08

Subcontractor’s Waiver of Lien (Partial) ........................................................................... C-09

Contractor’s Waiver of Lien (Final and Complete) ............................................................ C-10

Subcontractor’s Waiver and Release of Lien (Final) ........................................................ C-11

Consent of Surety to Final Payment .................................................................................. C-12

Any manipulations of these documents would be grounds for fraud and misrepresentation.

EXHIBIT E

C-01 – Application for Payment (Rev 100120)

APPLICATION FOR PAYMENT

Contract for: _______________________________________ Payment Application No.: ____________

County Contract No.: _______________ CIP No.: __________

CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS

Total changes approved in previous months by County $ $

Total approved this month $ $

TOTAL $ $

NET CHANGES by Change Order $

1. ORIGINAL CONTACT SUM ………………………………………………………………. $ _________________

2. NET CHANGE BY CHANGE ORDER .…………………………………………………… $ _________________

3. CONTACT SUM TO DATE (Line 1 & Line 2) ……………………………………………. $ _________________

4. TOTAL COMPLETED AND STORED TO DATE.……………………………………….. $ _________________

5. RETAINAGE:

(a) ________ % of Completed Work ……………………………… $ _________________

(b) ________ % of Stored Material ……………………………… $ _________________

Total Retainage (Lines 5a + 5b, or Total in Column 1) ……………………………….. $ _________________

6. TOTAL EARNED LESS RETAINAGE .……………………………………………………. $ _________________

7. LESS PREVIOUS CERTIFICATES FOR PAYMENT ……………………………………. $ _________________

(Line 6 from Prior Payment Application)

8. CURRENT PAYMENT DUE…………………………………………………………………. $ _________________

9. BALANCE TO FINISH INCLUDING RETAINAGE (Line 3 minus Line 6)………………. $ _________________

The undersigned Contractor certifies that (1) all previous payments for Work performed have been applied to discharge in full all obligations on the Contractor incurred in connection with Work covered by prior payment applications (1 through _____) under this Agreement; (2) all Materials and Equipment incorporated in the project are free and clear of liens, security interests and encumbrances; (3) all previous payments have been applied to pay in full, minus retainage, all amounts owed to its subcontractors and suppliers; (4) all information provided is true and accurate.

CONTRACTOR: ___________________________________ DATE: _______________

By: ________________________________ (Print) ___________________________ (Signature)

STATE OF FLORIDA

COUNTY OF

Sworn to (or affirmed) and subscribed before me by means of □ physical presence or □ online notarization, this day of ____________, 20___, by _______________________________________.(name of person making statement)

Signature of Notary Public – State of Florida Print/Type/Stamp Commissioned Name of Notary Public

Personally Known OR Produced Identification Identification Type: _______________________

COUNTY: In accordance with the Contract Documents, the undersigned recommend payment as presented.

Engineer: ____________________________________________ Date: _______________

Project Manager: ______________________________________ Date: _______________

APPLICATION DATE:

PERIOD TO:

PROJECT #

A B C D E F H I

MATERIALS

TOTAL

COMPLETED

% BALANCE RETAINAGE

FROM

PREVIOUS

PRESENTLY

STORED

AND STORED TO FINISH (IF VARIABLE

RATE)

APPLICATION NOT IN D OR E TO DATE (C - G)

(D + E) (D+E+F)

GRAND TOTALS

SEMINOLE COUNTY BOARD OF COUNTY COMMISSIONERS

Containing Contractor's signed certification is attached APPLICATION #:

WORK COMPLETED

G

UNIT SCHEDULED

VALUE

(original base bid value)

QTYITE

M #

CONTINUATION SHEET

DESCRIPTION OF WORK

THIS PERIOD (G / C)

APPLICATION AND CERTIFICATION FOR PAYMENT

C-01 (2) - Continuation Sheet - Application and Certification for Payment (Rev 100120)

C-01 (2) - Continuation Sheet - Application and Certification for Payment (Rev 100120)

C-02 - CHANGE ORDER FORM (Rev 100120)

CHANGE ORDER

CONSTRUCTION PROJECTS

CONTRACTOR: ________________________________________ Date: _________________

Contract No.: ____________________ Project Name: ___________________________________________________________

Change Order No.: _____________________ Work Order No.: (if applicable) _____________________

Original Contract / Work Order Amount: $ ________________

Amount prior to this Change Order, if different: $ ________________

Change Order Amount: Increase Decrease No Change $ ________________

Revised Contract / Work Order Amount including this Change Order: $ ________________

Change Order Time: Increase Decrease No Change ________________ Days

Date of Substantial Completion through this Change Order: ________________

Date of Final Completion through this Change Order: ________________

Waiver: This Change Order constitutes full and mutual accord and satisfaction for the adjustment of Contract / Work Order Price and Time as a result of increases or decreases in costs and time of performance caused directly and indirectly from the change. Acceptance of this Waiver constitutes an agreement between the County and Contractor that the Change Order represents an equitable adjustment to the Agreement and that Contractor will waive all rights to file a contract claim of any nature on this Change Order. Execution of this Change Order constitutes Contractor’s acceptance and satisfaction that it is entitled to no more costs or time, direct, indirect, impact, etc., pursuant to this Change Order.

Acknowledgements: The aforementioned change, and work affected thereby, is subject to all provisions of the original Agreement not specifically changed by this Change Order; and it is expressly understood and agreed by the County and the Contractor that the approval of this Change Order will have no effect on the original Agreement other than matters expressly provided herein.

This Change Order _______ does or ______ does not involve changes to the design of the project, which would require the approval and signature of the Architect or Engineer of Record and County Project Manager.

County Project Manager: Architect / Engineer of Record: Contractor:

Name: _________________________ _____________________________ ____________________________

Address: _________________________ ______________________________ ____________________________

Sign: _________________________ ______________________________ ____________________________

Date: _________________________ ______________________________ ____________________________

PURCHASING AND CONTRACTS DIVISION:

Signature: __________________________________________ Date __________________________________ Procurement Administrator As authorized by Section 3.554, Seminole County Administrative Code

WITNESS: ______________________________________ WITNESS: ____________________________________

For Board approved Items: Meeting Date: _____________________ Item # ____________________

Seminole County Board of County Commissioners

C-03 - Shop Drawing Submittal (Rev 100120)

SHOP DRAWING SUBMITTALS

Date: ___________________________ Submittal #: ___________________

ENGINEER OF RECORD: CONTRACTOR:

Attention: __________________________ Project Manager

Project Name: ____________________________________________________________

Contract No.: ________________ CIP# _________ Contractor: ______________________

Item No.

Copies Description Previous

Submission No.

Specification

Section(s) Plan

Sheet No.

Contractor’s Authorized Representative: ___________________________________________

TO BE COMPLETED BY ENGINEER OF RECORD:

Item No.

Copies Resubmit

Yes No

Comments

Engineer of Record: _________________________ Date: __________________

C-04 - Authorized Field Change (AFC) (Rev. 100120)

AUTHORIZED FIELD CHANGE (AFC)

FIELD ORDER NO.:

AGREEMENT TITLE:

CONTRACT NO.:

CIP #:

CONTRACTOR:

ARCHITECT/ENGINEER:

AGREEMENT DATE:

CONTRACT DAY: ______ OF _____

Note: An AFC is not an instrument that amends the Contract Documents. This AFC issued by ENGINEER to CONTRACTOR authorizes minor variations in the Work and not a change in the Work. An AFC does not entitle CONTRACTOR to any adjustment in Contract Price or Contract Time. FINAL AS-BUILT PLANS WILL REFLECT

AFC.

I. Minor Variations Authorized:

II. Justification

III. Acknowledgements: Mutually agreed to by the CONTRACTOR and the COUNTY.

This AFC authorized by:

Includes ____ attachments:

ARCHITECT/ENGINEER

By: ________________________________________________

Date: __________________________

Receipt of this AFC:

Acknowledged By:

CONTRACTOR

By: ________________________________________________

Date: __________________________

2 Pages Form

C-05 - CERTIFICATE OF SUBSTANTIAL COMPLETION (Rev 100120)

CERTIFICATE OF SUBSTANTIAL COMPLETION

Construction Projects

Contractor: ___________________________________ Date: __________________

Contract No.: _____________ Project Name: ___________________________________

Master Agreement (if applicable): ___________________________________________________

CIP No.: ___________________________

This Certificate of Substantial Completion applies to all work under the Contract Documents or the following specified parts thereof:

To: ______________________________________________________ (Print) Architect/Engineer of Record

Contractor

The work to which this Certificate applies has been inspected by authorized representatives of CONTRACTOR, and ARCHITECT/ENGINEER, and that Work is hereby declared to be substantially completed in accordance with the Contract Documents on:

Date of Substantial Completion

A list of items to be completed or corrected is attached hereto. This list may not be all-inclusive, and the failure to include an item in it does not alter the responsibility of CONTRACTOR to complete and warrant all the Work in accordance with the Contract Documents. All items on the list shall be completed or corrected by CONTRACTOR within ________ calendar days of the above date of Substantial Completion.

C-05 - CERTIFICATE OF SUBSTANTIAL COMPLETION (Rev 100120)

This Certificate does not constitute an acceptance of Work not in accordance with the Contract Documents nor is it a release of CONTRACTOR’s obligations to complete the Work in accordance with the Contract Documents, including “As-Built” drawings.

Executed by ARCHITECT/ENGINEER on the _______ day of _________________, 20____

ARCHITECT/ENGINEER:

Print Name

Signature

Accepted by CONTRACTOR on the _______ day of _________________, 20____

CONTRACTOR:

Executed by County’s PROJECT MANAGER on the _______ day of ________________, 20____

PROJECT MANAGER:

C-06 - CERTIFICATE OF FINAL COMPLETION (Rev 100120)

CERTIFICATE OF FINAL COMPLETION

Construction Projects

Contractor: ___________________________________ Date: __________________

Contract No.: _____________ Project Name: ___________________________________

Master Agreement (if applicable): ___________________________________________________

CIP No.: ___________________________

This Certificate of Final Completion applies to all work under the Contract Documents.

Architect/Engineer of Record

Contractor

To: Seminole County Board of County Commissioners or Designee

The Work to which this Certificate applies has been inspected on ________________ (date) by authorized representatives of CONTRACTOR, and ARCHITECT/ENGINEER, and that Work is hereby declared to be finally completed in accordance with the Contract Documents on:

Date of Final Completion

C-06 - CERTIFICATE OF FINAL COMPLETION (Rev 100120)

This Final Completion Certificate constitutes an acceptance of Work excepting latent defects, warranty work, maintenance, and other post Final Completion obligations of the CONTRACTOR under the Contract Documents.

Executed by ARCHITECT/ENGINEER on the _______ day of _________________, 20____

ARCHITECT/ENGINEER:

Accepted by CONTRACTOR on the _______ day of _________________, 20____

CONTRACTOR:

Accepted by SEMINOLE COUNTY on the _______ day of ________________, 20____

WITNESSES: BOARD OF COUNTY COMMISSIONERS

SEMINOLE COUNTY, FLORIDA

Procurement Administrator

As authorized by Section 3.554, Seminole County Administrative Code

C-07 - CONTRACTOR’S RELEASE (Rev 100120)

CONTRACTOR’S RELEASE

This Release must be submitted simultaneously with the Contractor’s request for Final Payment and Subcontractor Affidavits.

Agreement Title: County Contract No.:

Construction Contract # OR Master Services Agreement # & Work Order #

Contractor: ______ CIP No.:

BEFORE ME, the undersigned authority in said County and State, appeared

(Name of Affiant) who, being duly sworn and personally know to me, deposes and says that he/she is ___________________ (Title of Affiant) of ___ (Full Legal Company Name), a company and/or corporation authorized to do business under the laws of Florida, which is the CONTRACTOR on (Agreement Title), located in Seminole County, Florida, dated the _____ day of ___________, 20___, that the deponent is duly authorized to make this affidavit by resolution of the Board of Directors of said company and/or corporation; that deponent knows of their own knowledge that said Agreement has been complied with in every particular by said CONTRACTOR and that all parts of the Work have been approved by the COUNTY’s Architect/Engineer; that there are no bills remaining unpaid for labor, Materials, or otherwise, in connection with said Agreement and Word, and that there are no suits pending against the undersigned as CONTRACTOR or anyone in connection with the Work done and Materials furnished or otherwise under this Agreement.

Affiant further says that the final estimate in the amount of $ _______________ which has been submitted to the COUNTY simultaneously with the making of this affidavit constitutes all claims and demands against the COUNTY on account of said Agreement or otherwise, and that acceptance of the sum specified in said final estimate in the amount of $ ________________ will operate as a full and final release and discharge of the COUNTY from any further claims, demands or compensation by CONTRACTOR under the above Agreement.

Deponent further agrees that all guarantees under this Agreement shall start and be in full force from the date of this release as spelled out in the Contract Documents.

Affiant

State of Florida County of

Sworn to (or affirmed) and subscribed before me by means of □ physical presence OR □ online notarization, this __ day of , 20 , by .

(Name of Affiant)

Signature of Notary Public – State of Florida

Print, Type, Stamp Commissioned Name of Notary Public

Personally Known OR Produced Identification

Type of Identification Produced:

C-08 - CONTRACTOR’S WAIVER OF PARTIAL LIEN (Rev 100120)

CONTRACTOR’S WAIVER OF LIEN (Partial)

Copy of Waiver to be submitted with Each Pay Request

CIP No.:

From: ________________________________________________________________________

Full Legal Name of Contractor

To: Seminole County Board of County Commissioners

Pursuant to the Contract, identified above, entered into on the ______ day of ___________________, 20 ___, between the Contractor and Seminole County for the following project: _____________________________________________.

CONTRACTOR CERTIFIES THAT:

1. All Work covered by Application For Payment No: _______ has been performed in accordance with the terms of the Contract Documents;

2. The materialmen, subcontractors, mechanics, and laborers have been paid from previous payments received from the County on account of Work performed;

3. All Material and Equipment obligations of the Contractor have been paid from previous payments received from the County on account of Work performed; and

4. All just and lawful claims of the Contractor arising out of the performance of the Work covered by this Application for Payment have been paid and satisfied.

IN WITNESS WHEREOF, the undersigned has signed and sealed this instrument this _____ day of ___________________, 20 ___.

Witness:

Signature – Contractor’s Representative

Printed Name & Title

Sworn to (or affirmed) and subscribed before me by means of □ physical presence OR □ online notarization, this _____ day of _______________________, 20 , by ____________________________________.

Name of Person making statement

C-09 - SUB-CONTRACTOR’S WAIVER OF PARTIAL LIEN (Rev 100120)

SUB-CONTRACTOR’S WAIVER OF LIEN (Partial)

Copy of Waiver to be submitted with Each Pay Request

CIP No.:

From: ________________________________________________________________________

Full Legal Name of Sub-Contractor

To: Seminole County Board of County Commissioners

Pursuant to the Contract, identified above, entered into on the ______ day of ___________________, 20 ___, between the Contractor and Seminole County for the following project: _____________________________________________.

SUB-CONTRACTOR CERTIFIES THAT:

1. The materialmen, subcontractors, mechanics, and laborers have been paid from previous payments received from the County on account of Work performed;

2. All Material and Equipment obligations of the Contractor have been paid from previous payments received from the County on account of Work performed; and

3. All just and lawful claims of the Contractor arising out of the performance of the Work covered by this Application for Payment have been paid and satisfied.

IN WITNESS WHEREOF, the undersigned has signed and sealed this instrument this _____ day of ___________________, Signature – Sub-Contractor’s Representative

Sworn to (or affirmed) and subscribed before me by means of □ physical presence OR □ online notarization, this _____

C-10 - CONTRACTOR’S WAIVER OF FINAL AND COMPLETE LIEN (Rev 100120)

CONTRACTOR’S WAIVER OF LIEN (Final and Complete)

Copy of Waiver to be submitted with Final Pay Request

Agreement Title: County Contract No.: ________________________________

Contractor: ____________________________________ CIP No.:______________________________

_____________________________________ (Affiant), being duly sworn according to law, deposes and states that he/she is the ____________________________ (Title) of ____________________________________ (Full Legal Name of Contractor), Contractor in a Contract entered into between the Contractor and Seminole County for the _________________________________________________ (Agreement Title) and that he is authorized to and does make this affidavit on behalf of the Contractor.

THE AFFIANT FURTHER DEPOSES AND STATES THAT:

1. All Work has been performed in accordance with the terms of the Contract Documents, the Contractor alone has made all subcontracts, and the Contractor and his subcontractors have purchased all materials and fixtures and employed all labor in the performance of the Work.

2. All laborers, materialmen, mechanics, manufacturers and subcontractors who have furnished any one or all of the following: services, labor, fixtures, or materials have been satisfied and paid in full for the Work performed, and for materials, fixtures, and/or services supplied, and that the Contractor is not indebted to any person or firm in connection with the Work in any amount whatsoever.

3. There are no outstanding claims of any nature, contractual or otherwise, or for any personal injury, death or property damage, arising from or associated with the performance of the Work that might be the basis of any claim, suit, lien or demand that could be asserted against either the County or the Contractor.

4. All Bonds and Insurance policies required by the Contract are presently in effect and shall not be permitted to expire within the time periods stated in the Contract Documents.

5. This affidavit is made for the purpose of inducing the County to make Final Payment, and acceptance of such Final Payment by the Contractor shall release the County from any further liability under the Contract Documents.

IN WITNESS WHEREOF, the undersigned has signed and sealed this instrument this _____ day of ___________________, Signature – Contractor’s Representative

Sworn to (or affirmed) and subscribed before me by means of □ physical presence OR □ online notarization, this _____

C-11 - SUBCONTRACTOR’S WAIVER AND RELEASE OF LIEN (Rev 100120)

SUB-CONTRACTOR’S WAIVER AND RELEASE OF LIEN UPON FINAL PAYMENT

Copy of Waiver to be submitted with Contractor’s Final Pay Request

State of: _____________________ County of: _______________________

(Affiant), being duly sworn according to law, deposes and states that he/she is the (Title) of (Full Legal Name of Subcontractor), Subcontractor/Vendor/Lienor to the above Contractor under Contract with Seminole County for the (Agreement Title) and that he is authorized to and does make this affidavit on behalf of the Subcontractor.

The undersigned, in consideration of the final payment in the amount of $ , hereby waives its lien and right to claim a lien for labor, services, or materials furnished to (Contractor) on the above listed project to the following described property:

Property Address: _______________________________________________________________

Tax Parcel Number: ______________________________________________________________

Legal Description: _________________________________________________________________________________

IN WITNESS WHEREOF, the undersigned has signed this instrument this day of , 20 .

Signature of Subcontractor’s Representative Title

STATE OF FLORIDA

COUNTY OF:

The Foregoing instrument was acknowledged before me by means of □ physical presence OR □ online notarization, on this day of , 20 , by (Name of Affiant), who is personally known to me or who has produced as identification.

Printed/Typed/Stamped Commissioned Name of Notary Public

Title or Rank

Serial Number (if any)

C-12 - CONSENT OF SURETY TO FINAL PAYMENT (Rev 100120)

CONSENT OF SURETY TO FINAL PAYMENT

We, (Name of Surety), having heretofore executed Performance and

Payment Bonds for the above named Contractor covering the Project referenced above in the sum of

Dollars ($ ) hereby agree that the County may make full payment of the final estimate, including the retained percentage, to said Contractor. The Surety concurs that full payment to the Contractor is appropriate and the Surety expressly releases the County from all liability to Surety resulting from full payment to the Contractor.

It is fully understood that the granting of the right to the County to make payment of the final estimate to the Contractor and/or his assigns shall in no way relieve this Surety of its obligations under its bonds as set forth in the Contract Documents and Bonds pertaining to the above referenced Project. By execution of this Consent, Surety specifically acknowledges that, in the event it is discovered that the Contractor has failed to pay any subcontractors under this Project, the Surety will make such payments as are due, either in whole or in part, and hold the County harmless therefrom.

IN WITNESS WHEREOF, (Name of Surety) has caused this instrument to be executed on behalf of its and its duly authorized attorney-in-fact, and its corporate seal shall be affixed, on this _____ day of ___________________, 20 ___.

Signature – Surety’s Representative Signature – Attorney-in-Fact

*Power of Attorney must be attached if signed by Attorney-in-Fact

STATE OF FLORIDA

COUNTY OF:

The Foregoing instrument was acknowledged before me by means of □ physical presence OR □ online notarization, on this day of , 20 , by (Name of Affiant), who is personally known to me or who has produced as identification.

Printed/Typed/Stamped Commissioned Name of Notary Public

Title or Rank

Serial Number (if any)