State of: County of: Subscribed and sworn to before me this day of b. % of Stored Material $ 0.00

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1 APPLICATION AND CERTIFICATION FOR PAYMENT 702 PAGE ONE OF PAGES TO OWNER: PROJECT: APPLICATION NO: 004(Retention) Distribution to: OWNER ARCHITECT PERIOD TO: 6/20/18 X CONTRACTOR FROM SUB-CONTRACTOR: VIA ARCHITECT: YOUR COMPANY NAME PROJECT NO'S: COMMITMENT NO'S CONTRACT DATE: CONTRACTOR'S APPLICATION FOR PAYMENT Application is made for payment, as shown below, in connection with the Contract. Continuation Sheet, 703, is attached. The undersigned Contractor certifies that to the best of the Contractor's knowledge, information and belief the Work covered by this Application for Payment has been completed in accordance with the Contract Documents, that all amounts have been paid by the Contractor for Work for which previous Certificates for Payment were issued and payments received from the Owner, and that current payment shown herein is now due. 1. ORIGINAL CONTRACT SUM $ 52, Net change by Change Orders $ 12, CONTRACTOR: 3. CONTRACT SUM TO DATE (Line 1 ± 2) $ 64, TOTAL COMPLETED & STORED TO $ 64, DATE (Column G on 703) By: AUTHORIZED SIGNATURE Date: DATE OF APPLICATION 5. RETAINAGE: a. 0 % of Completed Work $ 0.00 State of: County of: (Column D + E on 703) Subscribed and sworn to before me this day of b. % of Stored Material $ 0.00 Notary Public: (Column F on 703) My Commission expires: Total Retainage (Lines 5a + 5b or Total in Column I of 703) $0.00 ARCHITECT'S CERTIFICATE FOR PAYMENT 6. TOTAL EARNED LESS RETAINAGE $ 64, In accordance with the Contract Documents, based on on-site observations and the data (Line 4 Less Line 5 Total) comprising the application, the Architect certifies to the Owner that to the best of the 7. LESS PREVIOUS CERTIFICATES FOR Architect's knowledge, information and belief the Work has progressed as indicated, PAYMENT (Line 6 from prior Certificate) $ 57, the quality of the Work is in accordance with the Contract Documents, and the Contractor 8. CURRENT PAYMENT DUE $ 6, is entitled to payment of the AMOUNT CERTIFIED. 9. BALANCE TO FINISH, INCLUDING RETAINAGE $ 0.00 (Line 3 less Line 6) AMOUNT CERTIFIED $ CHANGE ORDER SUMMARY ADDITIONS DEDUCTIONS (Attach explanation if amount certified differs from the amount applied. Initial all figures on this Total changes approved 12, Application and onthe Continuation Sheet that are changed to conform with the amount certified.) in previous months by NNI ARCHITECT: Total approved this Month 0.00 By: Date: TOTALS 12, This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herein. Issuance, payment and acceptance of payment are without NET CHANGES by Change Order prejudice to any rights of the Owner or Contractor under this Contract.

2 CONTINUATION SHEET 703 PAGE OF PAGES Company Name:YOUR COMPANY NAME Project Name: APPLICATION NO: 004(Retention) APPLICATION DATE: 6/20/18 PERIOD TO: 6/20/18 NNI's Commitment NO: A B C D E F G H I J ITEM DESCRIPTION OF WORK SCHEDULED WORK COMPLETED MATERIALS TOTAL % BALANCE RETAINAGE NO. VALUE FROM PREVIOUS THIS PERIOD PRESENTLY COMPLETED (G C) TO FINISH (IF VARIABLE APPLICATION STORED AND STORED (C - G) RATE) (D + E) (NOT IN TO DATE D OR E) (D+E+F) 1 Underground $15, $15, $ 0.00 $0.00 $15, % $0.00 $1, Wall Rough $22, $22, $ 0.00 $0.00 $22, % $0.00 $2, Finishes $14, $14, $ 0.00 $0.00 $14, % $0.00 $1, NNI Issued Change Order #1 $3, $3, $ 0.00 $0.00 $3, % $0.00 $ NNI Issued Change Order #2 $8, $8, $ 0.00 $0.00 $8, % $0.00 $ GRAND TOTALS $64, $64, $0.00 $0.00 $64, % $0.00 $6,405.80

3 CONDITIONAL WAIVER AND RELEASE OF LIEN UPON FINAL PAYMENT To All Whom It May Concern: The undersigned is to be paid a final payment in the sum of $ 6, (Amount) for labor, services, equipment, or material furnished NNI Construction. Upon receipt and when the check has been properly endorsed and has been paid by the bank upon which it is drawn, this document shall become effective to release any mechanic s lien, stop notice or bond right the undersigned has on the job of: Job Name: Address: City: County: County of Project State: This release covers the final payment to the undersigned for all labor, services, equipment, or material furnished on the job, except for disputed claims for additional work in the amount of $ Before any recipient of this document relies on it, the party should verify evidence of payment to the undersigned By: AUTHORIZED SIGNATURE Company Name: Print Name: of Authorized Signer Company Trade: YOUR COMPANY NAME Print Title: of Authorized Signer Dated: 6/20/18 SWORN TO BEFORE ME AND SUBSCRIBED IN MY PRESENCE, at, this 20th day of June A. D., NOTARY STAMP & SIGNATURE Wavier of Lien 2016

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