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SUBCONTRACTOR S APPLICATION FOR PAYMENT TO D. K. LIPPY CONSTRUCTION COMPANY FROM PROJECT PAYMENT REQUEST NO. PERIOD 20 TO 20 STATEMENT OF CONTRACT ACCOUNT 1. Original Contract Amount 2. Approved Change Order Nos. As per attached breakdown Net 3. Adjusted Contract Amount 4. Value of Work Completed to date As per attached breakdown 5. Value of Approved Change Orders Completed As per attached 6. Materials Stored on Site As per attached breakdown 7. Total to Date 8. Less Amount Retained 9. Total Less Retainage 10. Total Previously Certified Deduct Paid to Date 11. AMOUNT DUE THIS REQUEST CERTIFICATE OF THE SUBCONTRACTOR I hereby certify that the work preformed and the materials supplied to date as shown above represent the actual value of accomplishment under the terms of the Contract and all authorized changes thereto between the undersigned and D. K. Lippy Construction Co. 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 contractor to 1 all my subcontractors subsubcontractors and 2 for all materials and labor used in or in connection with the performance of this contract. I further certify I have complied with Federal State and Local tax laws including Social Security laws and Unemployment Compensation laws and Workman s Compensation laws in so far as applicable to the performance of this Contract. Date Subcontractor Subscribed and sworn before me this Authorized Signature Notary Public TITLE My commission expires. PERIOD 20 TO 20 STATEMENT OF CONTRACT ACCOUNT 1. Original Contract Amount 2. Approved Change Order Nos. As per attached breakdown Net 3. Adjusted Contract Amount 4. Value of Work Completed to date As per attached breakdown 5. As per attached breakdown Net 3. Adjusted Contract Amount 4. Value of Work Completed to date As per attached breakdown 5. Value of Approved Change Orders Completed As per attached 6. Materials Stored on Site As per attached breakdown 7. Value of Approved Change Orders Completed As per attached 6. Materials Stored on Site As per attached breakdown 7. Total to Date 8. Less Amount Retained 9. Total Less Retainage 10. Total Previously Certified Deduct Paid to Date 11. Total to Date 8. Less Amount Retained 9. Total Less Retainage 10. Total Previously Certified Deduct Paid to Date 11. AMOUNT DUE THIS REQUEST CERTIFICATE OF THE SUBCONTRACTOR I hereby certify that the work preformed and the materials supplied to date as shown above represent the actual value of accomplishment under the terms of the Contract and all authorized changes thereto between the undersigned and D. AMOUNT DUE THIS REQUEST CERTIFICATE OF THE SUBCONTRACTOR I hereby certify that the work preformed and the materials supplied to date as shown above represent the actual value of accomplishment under the terms of the Contract and all authorized changes thereto between the undersigned and D. K. Lippy Construction Co. 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 contractor to 1 all my subcontractors subsubcontractors and 2 for all materials and labor used in or in connection with the performance of this contract.

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