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Nts received, and that the current payment shown herein is now due. This Application for Payment is made according to the following determination: TOTAL COMPLETED & STORED TO DATE 1) RETAINAGE* (3% of line 1) CONTRACTOR Previous Retainage Retainage This Pay ADDRESS TOTAL RETAINAGE 2) TOTAL EARNED LESS RETAINAGE 3) LESS PREVIOUS CERTIFICATES 4) CITY/STATE/ZIP BY CURRENT PAYMENT DUE 5) TITLE *See General Conditions for retainage procedures and requirements for projects of differing si.

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