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PAYMENT APPLICATION NO. 3 #NTRACT SUMMARY: 1 - Original contract amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 659.709.90 2 - Additions approved to date (Itemize) (Nos. C.O. 1 ) . . . . . . . . . . . . . . . . . . . . $ 3.827.40 3 - Deductions approved to date (Itemize) (Nos. none ) $ 0 4 - Revised contract amount to date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S 663.537.30 STATUS OF ACCOUNT: 5 - Contract amount to date . . . . . . . . . . . . . . . . . . . . . . S 663.537.30 6 - Value of completed work to date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S 535.497.77 7 - Material stored on site (Attach Schedule) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ NA 8 - Less 5 per cent retained . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S 26.774.89 9 - Total earned less retained amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S 508.722.88 10 - Total of estimates previously approved . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 302.909.03 11 - Amount due this estimate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S 205.813.85 APPROVAL OF FIELD SUPERVISOR CERTIFICATE OF CONTRACTOR: • • I (We) certify that all work for which this request for payment is made has been completed in full, according to the Date - 1-7 " f plans and specifications and terms of the contract documents. I (We) also certify that payment has been made for all just claims for labor, material and services in connection with the APPROVAL OF ENGINEER: work performed on all preceding estimates. The work of the project and this estimate have been examined and the amount shown is recommended for MIDWEST ASPHALT CORPORATION payment. Firm Name Signature Signature Date �, Date � �f - •