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| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
|
| Name and
Address |
Kind of Work |
Contract |
Adjustments |
Total |
Net |
Net Amount |
Balance to |
|
| |
|
Amount |
to Contract |
Retained |
Previously |
of this |
Become |
|
| |
|
|
Incl. Extras |
Including |
Paid |
Payment |
Due (Incl. |
|
| |
|
|
and Credits |
this app. |
|
|
Retention) |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| Total from
Page 2 |
|
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
|
| TOTAL |
|
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
|
|
|
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
|
| Name and
Address |
Kind of Work |
Contract |
Adjustments |
Total |
Net |
Net Amount |
Balance to |
|
| |
|
Amount |
to Contract |
Retained |
Previously |
of this |
Become |
|
| |
|
|
Incl. Extras |
Including |
Paid |
Payment |
Due (Incl. |
|
|
|
|
and Credits |
this app. |
|
|
Retention) |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
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|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
|
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
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|
$0.00 |
|
| |
|
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|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
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|
|
$0.00 |
|
| |
|
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|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
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|
$0.00 |
|
| |
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|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
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|
|
$0.00 |
|
| |
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|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| |
|
|
|
|
|
|
$0.00 |
|
| TOTAL |
|
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
$0.00 |
|
|
| Signed |
_______________________________________ |
________________________________ |
_____________________ |
|
|
|
(Name &
Position) |
|
|
|
| Subscribed and sworn to before me this |
day of |
___________ |
, 20____. |
|
| |
|
____________________________________ |
|
|
Notary Public |
|
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|
