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|To: |The School Board of Broward County, Florida | | | | |SBBC | |

| | | | | | |Purchase | |

| | |Application No.: |      |Period To: | |Order No.: | |

| |(Owner via Project Consultant) | | | | | | |

|Project No: |      | | | | |

|Project Title: |      |Contractor: | |

|Facility Name: |      | | | | |

|Location No: |      | | | | |

|Change Order Summary |

|Change Orders approved by the School Board in |Additions |Deductions |

|previous months. | | |

|Total: | | |

|Approved this Month: | | |

|Number |Date Approved | | |

| | | | |

| | | | |

| |Totals | | |

| |Net change by | |

| |Change Orders: | |

The undersigned contractor certifies that to the best of the Contractor’s knowledge, information and belief the Work covered by this application for payment has been completed in accordance with the Contract Documents, that all amounts have been paid by the Contractor for Work for which previous Certificates for Payment were issued and payments received from the Owner and that current payment shown herein is now due.

|Contractor: | | |

|By: (Signature) | |Date: |

| | | |

|Notarization |State of Florida |County |

|Sworn Before me on this day of , . |

|Commission Expires: |

|Notary Public: | | |

Application is made for Payment, as shown below, in connection with the Contract. The Contractors updated Document 00435-Schedule of Values is attached as a continuation/detail sheet.

| | |

|1. ORIGINAL CONTRACT SUM |$ |

| | |

|2. NET CHANGE BY CHANGE ORDERS |$ |

|3. CONTRACT SUM TO DATE | |

|(Line 1 plus or minus line 2) |$ |

|4. TOTAL COMPLETED AND STORED TO DATE | |

|(Column H of Document 00435) |$ |

|5. RETAINAGE | |

|a. % of Completed Work $ | |

|(Column E + F of Document 00435) | |

|b. % of Completed Work $ | |

|(Column E + F of Document 00435) | |

|Total Retainage (Line 5a + 5b or total in Column K on Document 00435) | |

| |$ |

|6. TOTAL EARNED LESS RETAINAGE | |

|(Line 4 less Line 5 Total) |$ |

|7. LESS PREVIOUS CERTIFICATES FOR PAYMENT | |

|(Line 6 from previous certificate) |$ |

|8. CURRENT PAYMENT DUE | |

|(Enter this amount on Line 10 next page) |$ |

|9. BALANCE TO FINISH, PLUS RETAINAGE | |

|(Line 3 less Line 6) |$ |

Project Name: [pic] Project #:

Project Consultant’s Certificate for Payment

In accordance with the Contract Documents, based on on-site observations and the data comprising the above application, the Project Consultant’s certifies to the Owner that to the best of his knowledge, information and belief, the Work has progressed as indicated, the quality of the Work is in accordance with the Contract Documents, and the Contractor is entitled to payment in the AMOUNT CERTIFIED.

|AMOUNT CERTIFIED |$ |

|(Attach explanation if amount certified differs from the amount applied for.) |

|Project Consultant | |

| | |

|By: | |Date: | |

|(Signature) | |

This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Contract.

[pic] Contractor: [pic] Application #: [pic]

OWNER’S APPROVAL

|10. AMOUNT APPROVED | |

|(Attach explanation if amount approved differs from the amount certified above.) |

| | |

|Approved for Payment by: | |

| | |

|Project Manager: | |

| | |

|By: | |Date: | |

| |(Signature) | | |

| | | | |

| | | |

| | | |

|Deputy Director, CBRE/HEERY or Designee: | | |

| | | | |

|By: | |Date: | |

| (Signature) | | |

| | | |

|Director, Facilities Design & Construction or Designee: | | |

| | | | |

|By: | |Date: | |

| |(Signature) | | |

| | |

Executive Director, Capital Programs

|By: | |Date: | |

| |(Signature) | | |

This Approval is not negotiable. The AMOUNT APPROVED is payable only to the Contractor named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Contract.

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