CERTIFICATE OF PAYMENT

DATE : January 31, 1999 REFERENCE NO. :

PROJECT NO. : APPLICATION NO.:
PROJECT NAME :
LOCATION :
O W N E R :
CONTRACT FOR : CONTRACT DATE :
CERTIFICATE NO.:
TO :
D A T E ISSUED : January 31, 1999
FOR PERIOD FROM :
ATTN : TO

In accordance with the provision of the contract, and the attached application for payment, the named
Contractor is entitled to payment in the amount stipulated below.
PRESENT STATUS OF THE ACCOUNT FOR THE CONTRACT IS AS FOLLOWS :

ORIGINAL CONTRACT SUM : P

CHANGE ORDERS :
Total Additionals : P
Total Deductions : P
SUBTOTAL : P
TOTAL CONTRACT SUM : P

LESS DEDUCTIONS
CREDIT DUE TO OWNER : P
NET SUM TO DATE : P

TOTAL WORK EVALUATION : P

LESS 0.00 % RETENTION : P

TOTAL PREVIOUS COLLECTION : P

TOTAL AMOUNT THIS CERTIFICATE : P

THIS CERTIFICATE IS NOT NEGOTIABLE. IT IS PAYABLE ONLY TO THE PAYEE NAMED

HEREIN AND ITS ISSUANCE, PAYMENT AND ACCEPTANCE ARE WITHOUT PREJUDICE TO
ANY RIGHTS OF THE OWNER OR CONTRACTOR UNDER THEIR CONTRACT.
This payment shall not be considered an acceptance of any work or materials by the architect.

BY ARCHITECT: DATE : January 31, 1999

THIS IS TO CERTIFY THAT ALL ITEMS ARE PAID FOR WHICH PREVIOUS CERTIFICATES
WERE ISSUED AND PAYMENTS RECEIVED.

BY CONTRACTOR : DATE : January 31, 1999

ACCEPTED BY OWNER : DATE : January 31, 1999