EXHIBIT_G_Contractor_Release_Affidavit_Form.pdf
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- Solicitation number
- 2026-072-MC
- Issued by
- Lee County, Fruitville CDP, Florida
About this file
This is a Release and Affidavit form utilized by the Lee County Port Authority in Florida for contractor payment applications. The form serves as a legal document through which contractors release all claims, demands, damages, and expenses against the Lee County Port Authority, its Board of County Commissioners, employees, and agents related to work performed under a specific agreement. Contractors executing this affidavit certify that all charges for labor, materials, supplies, licenses, and other expenses have been fully satisfied and paid, and they agree to indemnify and defend the Authority from any liens, demands, or suits arising from their performance of work. The form is submitted in connection with either monthly or final applications for payment and must be notarized before a qualified notary public.
The affidavit requires contractors to provide identification details including the contract date, project performance period, payment amount received, and contractor information such as business name, executive officer signature, title, and corporate seal. The contractor must identify the specific application for payment number and whether it constitutes a monthly or final submission. Execution requires notarization with the notary public's signature, commission expiration date, and official seal affixed to the document. This form is a standard requirement for the Progressive Design-Build project involving parking garage construction, Quick Turnaround Area development, and demolition/remediation of existing facilities at Southwest Florida International Airport.
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Text version
RELEASE AND AFFIDAVIT
COUNTY OF________________
STATE OF ________________
Before me, the undersigned authority, personally appeared _________________________________________, who after being duly sworn, deposes and says:
(1) In accordance with the Contract Documents and in consideration of $_______________ paid, ___________________________________________________________ ("Contractor") releases and waives for itself and its subcontractors, materialmen, successors and assigns, all claims demands, damages, costs and expenses, whether in contract or in tort, against Lee County Port Authority (the "AUTHORITY"), via the Lee County Board of County Commissioners, employees and agents relating in any way to the performance of the Agreement between Contractor and the AUTHORITY, dated _______________, ____, for the period from ________________ to
(2) Contractor certifies for itself and its subcontractors, materialmen, successors and assigns, that all charges for labor, materials, supplies, lands, licenses and other expenses for which the AUTHORITY might be sued or for which a lien or a demand against any payment bond might be filed, have been fully satisfied and paid.
(3) Contractor agrees to indemnify, defend and save harmless the AUTHORITY, its Board of County Commissioners, employees and agents from all demands or suits, actions, claims of liens or other charges filed or asserted against the AUTHORITY arising out of the performance by Contractor of the Work covered by this Release and Affidavit.
(4) This Release and Affidavit is given in connection with Contractor's [monthly/final] Application for Payment No._____.
CONTRACTOR:
By: ____________________________________ (signature of the executive officer)
Its:_____________________________________ (title of the executive officer)
Date:___________________________
Witnesses
[Corporate Seal]
STATE OF _____________
COUNTY OF ______________
The foregoing instrument was acknowledged before me this ______ day of _______________, _______, by _______________________, as ____________________ of ____________________________________, a _______________ corporation, on behalf of the corporation. He/she is personally known to me or has produced ________________ ____________________________ as identification and did (did not) take an oath.
My Commission Expires: _______________________________________ (Signature of Notary)
Name:__________________________________ (Legibly Printed)
(AFFIX OFFICIAL SEAL) Notary Public, State of________________
Commission No.:________________________
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