[D]_Payment_And_ContractCompletion_Forms.pdf

COPY OF AFFIDAVIT TO BE PRESENTED WITH EACH PAY REQUEST

AFFIDAVIT

STATE OF

COUNTY OF

FROM:

(Contractor's Name)

TO: THE CITY OF ST. CLOUD

RE: Contract entered into the day of 20 , between the above-mentioned parties for the following project:

ITB No. _____

KNOW ALL MEN BY THESE PRESENTS:

The Undersigned hereby certifies that all work covered by Monthly Progress Payment Request No.

_____ has been performed in accordance with the terms of the above Contract, that all materialmen, subcontractors, mechanics and laborers have been paid in full in accordance with the contract terms and conditions and that all just and lawful claims arising out of the performance of the work covered by said Progress Payment Request have been paid and satisfied as stipulated by the Contract.

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

(Company Name)

By:

STATE OF __________________________________

COUNTY OF ________________________________

The foregoing instrument was acknowledged before me by means of physical presence or online notarization, this (date) by (name of officer or agent, title of officer or agent) of (name of corporation acknowledging), a (state or place of incorporation) corporation, on behalf of the corporation. He/she is personally known to me or has produced (type of identification) as identification.

[Notary Seal] Notary Public Name typed, printed or stamped

My Commission Expires: ____________

PARTIAL PAYMENT AUTHORIZATION NO.

PROJECT NAME: ITB No._____ __________

OWNER: The City of St. Cloud

CONTRACTOR:

DATE:

Contract Time Substantial 300 Final 360 Revised Remaining On Schedule No

Yes Starting Date % Complete

1.) Original Contract $

2.) Change Orders $

3.) Revised Contract $ (1 + 2)

4.) Work Completed $ this Period

5.) Retainage this $ Period (5%)

6.) Work Completed $ to Date

7.) Retainage to Date $

8.) Previous Payments $

9.) Amount Due (6-7-8) $

PARTIAL PAYMENT AUTHORIZATION Page 2

CONTRACTOR'S CERTIFICATION: The undersigned Contractor certifies that, to the best of their knowledge, information and belief, the work covered by this partial payment authorization has been completed in accordance with the contract documents, that all amounts have been paid by the Contractor for work for which previous partial payment requests were issued, and payments received from the Owner, and that the current payment shown herein is now due.

PROJECT MANAGER CERTIFICATION: The undersigned certifies that the work has been carefully inspected and to the best of their knowledge and belief, the quantities shown in this estimate are correct and the work has been performed in accordance with the contract documents.

1. REQUESTED BY: 3. ACCEPTED FOR CITY:

(Print Contractor's Name) (Print Project Manager's Name)

(Signature) Signature)

(Date) (Date)

2. VERIFIED BY: 4. APPROVED BY DEPARTMENT:

FIELD INSPECTOR PARKS AND RECREATION DEPARTMENT

(Signature) (Signature)

(Date) (Date)

PARTIAL PAYMENT AUTHORIZATION Page 3

PARTIAL WAIVER AND RELEASE FOR PROGRESS PAYMENT

The undersigned lienor, in consideration of the sum of $ hereby waives and releases its lien and right to claim a lien for labor, services, or materials furnished through to:

For the project: ITB No._____ __________

This waiver and release does not cover any retention or labor, services, or materials furnished after the date specified above.

Dated this day of 20 .

Lienor’s Name:

Address:

Signed By:

(Print Name & Title)

The foregoing instrument was acknowledged before me by means of physical presence or online notarization, this (date) by (name of officer or agent, title of officer or agent) of (name of corporation acknowledging), a (state or place of incorporation) corporation, on behalf of the corporation. He/she is personally known to me or has produced (type of identification) as identification.

[Notary Seal] Notary Public

CONTRACT CHANGE ORDER Change Order No.

Date Page of

ITB No. _____ __________

(Contract For/ITB No. and Project Name) City of St. Cloud, Florida (Owner)

(Contractor)

You are hereby requested to comply with the following changes from the contract plans and specifications:

DESCRIPTION OF CHANGES (Supplemental Plans and specifications attached)

DECREASE INCREASE

TOTAL INCREASE PER ATTACHMENT ‘A’ $ $

TOTAL DECREASE PER ATTACHMENT ‘B’ $ $

TOTALS $ $

NET CHANGE IN CONTRACT PRICE $ $

JUSTIFICATION:

The amount of the Contract will be (Decreased) (Increased) by the Sum of:

Dollars ($ ).

The Contract Total including this and previous Change Orders will be:

Dollars ($ ).

The Contract completion date will be (Increased)(Decreased)(Unchanged): Days.

This document will become a supplement to the contract and all provisions will apply hereto.

1. REQUESTED BY: 3. REVIEWED BY:

Contractor (Date) Finance Director (Date)

2. RECOMMENDED BY: 4. APPROVED BY:

Project Manager (Date) Owner / City Manager (Date)

CONTRACT CHANGE ORDER CHANGE ORDER #

INCREASES TO CONTRACT ATTACHMENT ‘A’

Item Description Quantity Unit Price Total

TOTAL INCREASE - C.O. #

CONTRACT CHANGE ORDER CHANGE ORDER #

DECREASES TO CONTRACT ATTACHMENT ‘B’

Item Description Quantity Unit Price Total

TOTAL DECREASE - C.O. #

CERTIFICATE OF SUBSTANTIAL COMPLETION

DATE:

The work performed under the Contract dated , between the City of St.

Cloud (OWNER) and (CONTRACTOR) for the construction of ITB No. _____ __________ was found to be substantially completed as of (date).

The term "Substantial Completion" shall mean that the construction is sufficiently completed in accordance with the Plans and Specifications, as modified in any Change Order agreed to by the parties, so that the Owner can utilize the facility for the use for which it was intended.

A list of items to be completed or corrected is appended hereto. This list may not be exhaustive and the failure to include an item on it does not alter the responsibility of the Contractor to complete all the work in accordance with the Contract Documents, including authorized changes thereto.

The Contractor will complete or correct the work on the list of items appended hereto within thirty (30) calendar days from the date of Substantial Completion.

Owner assumed full possession of the facility above described on (date). The responsibility of the Contractor to provide utilities under the Contract Documents shall cease that date and the one-year warranty period shall begin. Insurance coverage shall continue in accordance with provisions as amended of the Contract Documents.

CITY OF ST. CLOUD: (Name of Contractor)

City Manager Signature (Signature)

Project Manager Signature Print / Type Name & Title

CERTIFICATE OF CONTRACT COMPLETION

OWNER: City of St. Cloud, Florida

PROJECT: ITB No. _____ __________

CONTRACTOR:

CONTRACT DATE: CONTRACT AMOUNT:

CONTRACTOR'S AFFIDAVIT

I solemnly swear (or affirm): That the work under the above named Contract and all Amendments thereto have been satisfactorily completed; that all amounts payable for materials, labor and other charges against the project have been paid; that no liens have been attached against the project; that no suits are pending by reason of work on the project under the Contract; that all Workers' Compensation claims are covered by Workers' Compensation insurance as required by law; and that all public liability claims are covered by insurance.

(SEAL) (Name of Contractor)

Date:

The foregoing instrument was acknowledged before me by means of physical presence or online notarization, this (date) by (name of officer or agent, title of officer or agent) of (name of corporation acknowledging), a (state or place of incorporation) corporation, on behalf of the corporation. He/she is personally known to me or has produced (type of identification) as identification.

[Notary Seal] Notary Public

CERTIFICATE OF ENGINEER/PROJECT MANAGER

CERTIFICATE OF ENGINEER/PROJECT MANAGER

I CERTIFY: That the work under the above-named Contract has been satisfactorily completed under the terms of the Contract; that the project is recommended for occupancy by the Owning Agency; that the Contractor has submitted satisfactory evidence that he has paid all labor, materials and other charges against the project in accordance with the terms of the Contract.

Date Days

Contract Date

Contractor Notified to Proceed

Days Allowed by Contract

Extensions Granted by C.O.

Total Days Allowable

Work Began

Project Completed

City of St. Cloud 1300 9th Street St. Cloud, Florida 34769

Date: By:

Project Manager

Date: By:

ENGINEER

CERTIFICATE OF ACCEPTANCE BY USING AGENCY

THIS IS TO CERTIFY: That to the best of my knowledge and belief the statements made in the above affidavit and certificate is true, and the project is satisfactorily completed under the terms of the Contract and is hereby accepted for occupancy, operation and maintenance.

By:

Parks and Recreation Department

STATE OF __________________________________

COUNTY OF ________________________________

The foregoing instrument was acknowledged before me by means of physical presence or online notarization, this (date) by (name of officer or agent, title of officer or agent) of (name of corporation acknowledging), a (state or place of incorporation) corporation, on behalf of the corporation. He/she is personally known to me or has produced (type of identification) as identification.

[Notary Seal] Notary Public Name typed, printed or stamped

My Commission Expires: ____________

Owner: THE CITY OF ST. CLOUD

By:

Title:

STATE OF __________________________________

COUNTY OF ________________________________

The foregoing instrument was acknowledged before me by means of physical presence or online notarization, this (date) by (name of officer or agent, title of officer or agent) of (name of corporation acknowledging), a (state or place of incorporation) corporation, on behalf of the corporation. He/she is personally known to me or has produced (type of identification) as identification.

[Notary Seal] Notary Public

PRIME CONTRACTOR REQUEST FOR FINAL PAYMENT

COUNTY OF

, being duly sworn according to law, deposes and says that he is the President (Title of Office) of , the Contractor, in a Contract entered into between the Contractor and the Owner, for ITB No. _____ __________, and that he is authorized to and does make this affidavit in behalf of said Contractor.

The affiant further deposes and says:

1.) That all work has been performed in accordance with the terms of said Contract, the Contractor alone has made all subcontracts, and the Contractor and his subcontractors have purchased all materials and fixtures and employed all labor used in the performance of this Contract.

2.) That all laborers, materialmen, mechanics, manufacturers and subcontractors who have furnished services, labor, fixtures, or materials or any one or all of these items have been satisfied and paid in full for the work performed, materials, fixtures or services supplied at the agreed price or reasonable value of such materials and labor; that the said Contractor is not indebted to any person or labor or materials used in connection with such project in any amount whatsoever.

3.) That 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 said Contract that might be the basis of any claim, suit, lien, or demand that could be asserted against either the Owner or the Contractor.

4.) This affidavit is made for the purpose of inducing the Owner to make final payment, and acceptance of such final payment by Contractor shall release the Owner from any further liability under the Contract.

Authorized Signer (Title)

STATE OF __________________________________

COUNTY OF ________________________________

The foregoing instrument was acknowledged before me by means of physical presence or online notarization, this (date) by (name of officer or agent, title of officer or agent) of (name of corporation acknowledging), a (state or place of incorporation) corporation, on behalf of the corporation. He/she is personally known to me or has produced (type of identification) as identification.

[Notary Seal] Notary Public

SUBCONTRACTOR FINAL AFFIDAVIT

AFFIDAVIT

COUNTY OF

, being duly sworn according (Individual's Name) to law, deposes and says that he is the (title) of (Name of Subcontractor's Company) Subcontractor for the (Type of installation) work under , the Contractor, in Contract entered into between the Contractor and the City of St. Cloud, Florida, the Owner, for ITB No. _____ __________ and that he is authorized to and does make this affidavit in behalf of said Subcontractor. The affiant further deposes and says:

1.) That all laborers, materialmen, mechanics, manufacturers and subcontractors who have furnished services, labor, fixtures or materials or any one or all of these items have been satisfied and paid in full for the work performed, materials, fixtures, or services supplied at the agreed price or reasonable value, and there are no claims, liens, or demands of any nature in connection with the performance of the work under this Contract.

2.) That I, (Subcontractor) have received full payment of the total consideration for the work/services/materials under said Contract, the receipt of which is hereby acknowledged and that I have no lien or claim of any nature against any person or property which may be the basis of any suit, claim or demand against either the Owner or the Contractor.

(Signature of Affiant)

The foregoing instrument was acknowledged before me by means of physical presence or online notarization, this (date) by (name of officer or agent, title of officer or agent) of (name of corporation acknowledging), a (state or place of incorporation) corporation, on behalf of the corporation. He/she is personally known to me or has produced (type of identification) as identification.

[Notary Seal] Notary Public