Form 700-050-21 (21-A) "Contractor's Affidavit and Surety Consent" - Florida

What Is Form 700-050-21 (21-A)?

This is a legal form that was released by the Florida Department of Transportation - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2009;
  • The latest edition provided by the Florida Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 700-050-21 (21-A) by clicking the link below or browse more documents and templates provided by the Florida Department of Transportation.

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Download Form 700-050-21 (21-A) "Contractor's Affidavit and Surety Consent" - Florida

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Rule 14-24.001 F.A.C.
STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION
700-050-21
CONTRACTOR’S AFFIDAVIT AND SURETY CONSENT
Rule 14-79.006 F.A.C.
CONSTRUCTION
12/2009
(FORM 21-A)
Page 1 of 2
STATE OF FLORIDA
COUNTY OF
Before me, the undersigned Notary Public, personally appeared
to me well known or who has produced
as identification,
(Type of Identification)
who being first duly sworn, deposes and says that he/she is:
(Title of duly authorized person)
of
a
,
(Contracting entity)
(Type of entity)
the Contractor on Financial Project I.D.
, Road No.
in
County, Florida under Contract No.
with the State of Florida Department of Transportation dated the
day of
,
;
and that the Affiant based on his/her personal knowledge says that:
1.
Said contract has been complied with in every particular by the Contractor and that all parts of the work have been approved
by the District Director of Operations of the State of Florida Department of Transportation.
2.
The Contractor has not offered or made any gift or gratuity to, or made any financial transaction of any nature with, any
employee of the Department in connection with obtaining or performing said contract.
3.
All amounts payable for labor, materials, or otherwise, in connection with said contract and work have been paid except for
normal sub-contract retainages, which will be satisfied within 30 days after payment and/or release of retainage withheld under said
contract.
4.
There are no claims or suits pending against said Contractor or anyone in connection with the work done, materials furnished
or otherwise, under said contract except as listed below. As to any such exception listed below, the Contractor has stated the name of
the entity making the claim, the name of the entity against whom the claim is being made, and demonstrated below good cause as
required by Section 337.11(11), Florida Statutes.
Claiming Entity
Claim Agent
Nature of claim
Good cause explanation
A false statement or omission made in connection with this affidavit is
State of Florida
sufficient cause for suspension, revocation, or denial of qualification to bid,
County of _____________________
and a determination of non-responsibility, and may subject the person and/or
entity making the false statement to any and all civil and criminal penalties
available pursuant to applicable Federal and State Law.
Sworn to and subscribed before me this _____________ day
of ___________ , ____ , by ____________________________
____________________________________________________________
Contractor
(Print name of person signing Affidavit)
____________________________________________________________
By
Notary Public
,not required when digital
____________________________________________________________
Title
_______________________
Commission Expires
Personally Known ____ OR Produced Identification ______
Type of Identification Produced _________________________
Rule 14-24.001 F.A.C.
STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION
700-050-21
CONTRACTOR’S AFFIDAVIT AND SURETY CONSENT
Rule 14-79.006 F.A.C.
CONSTRUCTION
12/2009
(FORM 21-A)
Page 1 of 2
STATE OF FLORIDA
COUNTY OF
Before me, the undersigned Notary Public, personally appeared
to me well known or who has produced
as identification,
(Type of Identification)
who being first duly sworn, deposes and says that he/she is:
(Title of duly authorized person)
of
a
,
(Contracting entity)
(Type of entity)
the Contractor on Financial Project I.D.
, Road No.
in
County, Florida under Contract No.
with the State of Florida Department of Transportation dated the
day of
,
;
and that the Affiant based on his/her personal knowledge says that:
1.
Said contract has been complied with in every particular by the Contractor and that all parts of the work have been approved
by the District Director of Operations of the State of Florida Department of Transportation.
2.
The Contractor has not offered or made any gift or gratuity to, or made any financial transaction of any nature with, any
employee of the Department in connection with obtaining or performing said contract.
3.
All amounts payable for labor, materials, or otherwise, in connection with said contract and work have been paid except for
normal sub-contract retainages, which will be satisfied within 30 days after payment and/or release of retainage withheld under said
contract.
4.
There are no claims or suits pending against said Contractor or anyone in connection with the work done, materials furnished
or otherwise, under said contract except as listed below. As to any such exception listed below, the Contractor has stated the name of
the entity making the claim, the name of the entity against whom the claim is being made, and demonstrated below good cause as
required by Section 337.11(11), Florida Statutes.
Claiming Entity
Claim Agent
Nature of claim
Good cause explanation
A false statement or omission made in connection with this affidavit is
State of Florida
sufficient cause for suspension, revocation, or denial of qualification to bid,
County of _____________________
and a determination of non-responsibility, and may subject the person and/or
entity making the false statement to any and all civil and criminal penalties
available pursuant to applicable Federal and State Law.
Sworn to and subscribed before me this _____________ day
of ___________ , ____ , by ____________________________
____________________________________________________________
Contractor
(Print name of person signing Affidavit)
____________________________________________________________
By
Notary Public
,not required when digital
____________________________________________________________
Title
_______________________
Commission Expires
Personally Known ____ OR Produced Identification ______
Type of Identification Produced _________________________
Rule 14-24.001 F.A.C.
STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION
700-050-21
CONTRACTOR’S AFFIDAVIT AND SURETY CONSENT
Rule 14-79.006 F.A.C.
CONSTRUCTION
12/09
Page 2 of 2
(FORM 21-A)
We, the
, duly authorized to do business under the laws of Florida, having
(Type or print name of Surety)
heretofore executed a performance and payment bond for the Contractor covering the contract described above, hereby
consent the State of Florida Department of Transportation making full payment of the final estimate, including the retained
percentage, to the Contractor.
It is fully understood that consenting to the State of Florida Department of Transportation making payment of the final
estimate to the Contractor and/or its assignee, shall not relieve this surety company of any of its obligations under its
bond.
IN WITNESS WHEREOF, the
has caused this
(Type or print name of surety)
instrument to be executed by its President, Chief Executive Officer or duly authorized Attorney-In-Fact and its corporate
seal to be hereto affixed, all on this
day of
,
.
SURETY COMPANY
(AFFIX SEAL)
BY: ______________________________
Its President or Chief Executive Officer
Its Attorney-In-Fact
Florida Licensed Insurance Agent
(Attach Power of Attorney)
STATE OF _____________________________
COUNTY OF ___________________________
Before me, the undersigned Notary Public, personally appeared _______________________ to me well known or who
has produced _______________________ as identification as the person described in and who executed the foregoing
(Type of Identification)
instrument in the name of ______________________________________________ and ______________________
acknowledged that he/she executed said instrument in the name of said surety as its ___________________________
for the purposes therein expressed and that he/she has due and legal authority to execute the same on behalf of said
surety.
Sworn to and subscribed before me this ________ day of ___________ , ____________
______________________________________
My commission expires _______________________
Notary Public, State of ________________________
Rule 14-24.001 F.A.C.
700-050-21
Rule 14-79.006 F.A.C.
CONSTRUCTION
12/09
INSTRUCTIONS
1. If the Contractor is a corporation, the document must be signed by its President/Vice President or an officer
authorized to legally bind the corporation. Please include the corporate title of the Deponent on the line provided. If
an individual or officer other than the President or Vice President signs, attach a copy of the authorization.
2. If the Contractor is any other entity, the document must be signed by an officer or director authorized to bind the
entity. Please include the title of the Deponent on the line provided.
3.
Any claims or pending suits for labor, materials, unpaid bills or liability damages against the Contactor in connection with the
contract and work are to be listed in the spaces provided on the form. If space is inadequate, attach additional sheet(s) of
paper thereto with initials of Deponent and surety affixed and dated. As to any such claims or suits, state the name of the
entity making the claim, the name of the entity against whom the claim is being made, and demonstrate good cause as
required by Section 337.11(11), Florida Statutes. The Prime Contractor should list only those claims in dispute with a Sub-
Contractor (as defined in Section 9-5.6 of the Specifications). Proof of adequate liability insurance coverage in effect during
the life of the contract must be attached when tort liability claims are listed.
4. The execution by the representatives of the entity and the surety must be sworn to before a notary public and the
surety seal affixed. If executed by any other officer, please attach a certificate of authority.
5. The document must be executed in the name of the surety company by its President or Chief Executive Officer and
the surety seal affixed. If executed by any other officer, please attach a certificate of authority.
6. If the document is executed in the name of the surety company by an attorney-in-fact, a power of attorney with the
surety seal, dated the date of execution, must accompany the document and must grant the attorney-in-fact the
authority to execute consents for the release of retained percentages and/or final estimates on engineering and
construction contracts, or similar authority. The date of execution and the date of notarization on Page 2 and the date
of the certificate on the power of attorney must be the same date.
The power of attorney language authorizing execution of consents for the release of retained percentages must be
authorized by the surety company. Power of attorney certificates will be rejected where there is no assurance that
such language is the surety's original language.
THE USUAL POWER OF ATTORNEY FOR EXECUTION OF BONDS DOES NOT GRANT THE POWER TO
EXECUTE THESE CONSENTS.
7. Each power of attorney must be an original copy or be certified to by manual signature unless evidence is furnished
that the surety company has authorized the use of facsimile signatures.
8. All appropriate blanks should be filled. No erasures or "white outs" are permitted. Corrections may be made by lining
through the incorrect entry, entering the correct information, and having the change initialed by the person executing
the form.
9. Failure to comply with the above requirements will result in return of the document and delay in payment of the final
estimate.
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