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DocuSign Envelope ID:4E36FD70-9689-46BE-A761-56385A3E3120 APPLICATION PAYMENT ORIGINALS DUE BY THE 25th - For Internal Use Only To: J.Raymond Construction Corp. SC x 466 W.Warren Avenue Control: 19-022 MI Longwood,Florida 32760 PO From: ACS Fire&Security 6901 TPC Drive Suite 200 Orlando,Florida 32822 Vendor#: Code: 19022.16600A Gross: Retain: Project: 19-022-Zephyr Commons Self Storage Net: Contract: 19022.16800A Approved: Payment Request#: Period From: To: Contract Executed? Y N Joint Checks? Y N Federal ID M Insurance in Effect? Y N STATEMENT OF CONTRACT AMOUNT: 1. Original Contract Amount $7,100.00 JRCC USE ONLY 2. Approved Change Order#'s $ Pending Change Order Vs $ 3. Adjusted Contract Amount( 1 +2 ) $ 4. Values of Work Completed to Date $ 5. Material Stored on Site $ 6. Total to Date (4 + 5) $ 7. Less Amount Retained (10%) $ 8. Total Less Retainage (6 -7 ) $ 9. Total Previously Certified (Deduct) $ 10. AMOUNT DUE THIS REQUEST Is CERTIFICATE OF THE SUBCONTRACTOR: I hereby certify that the work performed and the materials supplied to date, as shown above, represent the actual value of accomplishment under the terms of the contract(and all authorized change thereto) between the undersigned and J. Raymond Construction Corp. relating to the above referenced project. I also certify that payments, less applicable retention, have been made through the period covered by previous payments received from the contractor to (1)all my subcontractors and (2)for all materials and labor used in or in connection with the performance of this Contract. Subcontractor does further warrant that should any claim or lien be filed for material supplied or labor performed by virtue of subcontractor's participation in the construction of said improvements. Subcontractor will immediately furnish a bond for release of each such lien, and obtain settlement of any such liens and furnish Owner and Contractor written full release of such liens.Should subcontractor be unable to obtain such release,subcontractor agrees to fully indemnify and hold harmless the Contractor and Owner for any and all costs that may occur by reason of such liens. I further certify I have complied with Federal, State,and local tax laws, including Social Security laws and Unemployment Compensation laws and Workmen's Compensation laws insofar as applicable to the performance of this Contract. Subscribed and sworn before me this day Of , 20 Subcontractor: Notary Public By: My Commission Expires Title: