AGREEMENT between BROWARD COUNTY and Cummings ...

Exhibit 2
Page 379 of 379
CERTIFICATION OF PAYMENTS TO SUBCONTRACTORS & VENDORS
Project Title Terminal 4 Gate Replacement
RLI No. R0787918R1
The undersigned CONTRACTOR for the referenced project hereby swears under
penalty of perjury that:
1. CONTRACTOR has paid all subcontractors all undisputed contract obligations
for labor and services, provided on this project in accordance with this
Agreement, except as provided in paragraph 2 below.
2. The following subcontractors have not been paid because of disputed contractual
obligations; 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 and address Date of disputed invoice Amount in Dispute
Dated _____________, 20___
STATE OF ______________
COUNTY OF ____________ SS.
By _________________________________
(Signature of Contractor Authorized Representative/Office)
By ________________________________
(Name and Title)
The foregoing instrument was acknowledged before me this ________ day of
__________________, 20__, by _____________________________ who is personally
known to me or who has produced _____________________ as identification and who
did/did not take an oath.
WITNESS my hand and official seal, this ______ day of ___________, 20__.
(NOTARY SEAL)
(Serial number, if any)
My commission expires:
_________________________________
(Signature of person taking acknowledgment)
_________________________________
(Name of officer taking acknowledgment)
typed, printed or stamped
__________________________________
(Title or rank)