K-2 - Pay Application 4 - Final - All American Concrete - Kimberlite South Improvements

PAYMENT APPLICATION TO: City of Tiffin P.O. Box 259 Tiffin, Iowa 52340 Attn: FROM: All American Concrete, Inc. 1489 Highway 6 West Liberty, IA 52776 FOR: Kimberlite St.-South Improvements PROJECT NAME AND LOCATION: Kimberlite St.-Tiffin Kimberlite St.-South Improvements ARCHITECT: Tiffin, Iowa 52340 APPLICATION # 4 Final Distribution to: PERIOD THRU: 10/08/2024 OWNER PROJECT #: ARCHITECT DATE OF CONTRACT: 03/20/2024 CONTRACTOR CONTRACTOR'S SUMMARY OF WORK Application is made for payment as shown below. Continuation Page is attached. 1. CONTRACT AMOUNT $248,581.55 2. SUM OF ALL CHANGE ORDERS $0.00 3. CURRENT CONTRACT AMOUNT (Line 1 +/- 2) $248,581.55 4. TOTAL COMPLETED AND STORED (Column G on Continuation Page) $252,240.50 5. RETAINAGE: a. 0.00% of Completed Work (Columns D + E on Continuation Page) $0.00 b. 0.00% of Material Stored (Column F on Continuation Page) $0.00 Total Retainage (Line 5a + 5b or Column I on Continuation Page) $0.00 6. TOTAL COMPLETED AND STORED LESS RETAINAGE (Line 4 minus Line 5 Total) $252,240.50 7. LESS PREVIOUS PAYMENT APPLICATIONS $247,840.50 8. PAYMENT DUE $4,400.00 9. BALANCE TO COMPLETION (Line 3 minus Line 6) ($3,658.95) <table> <tr> <th>SUMMARY OF CHANGE ORDERS</th> <th>ADDITIONS</th> <th>DEDUCTIONS</th> </tr> <tr> <td>Total changes approved in previous months</td> <td>$0.00</td> <td>$0.00</td> </tr> <tr> <td>Total approved this month</td> <td>$0.00</td> <td>$0.00</td> </tr> <tr> <td>TOTALS</td> <td>$0.00</td> <td>$0.00</td> </tr> <tr> <td>NET CHANGES</td> <td>$0.00</td> <td></td> </tr> </table> Contractor's signature below is his assurance to Owner, concerning the payment herein applied for, that: (1) the Work has been performed as required in the Contract Documents, (2) all sums previously paid to Contractor under the Contract have been used to pay Contractor's costs for labor, materials and other obligations under the Contract for Work previously paid for, and (3) Contractor is legally entitled to this payment. CONTRACTOR: All American Concrete, Inc. By: Jodi Simon Date: 10-8-24 State of: Iowa County of: Muscatine Subscribed and sworn to before me this 8th day of October 2024 Notary Public: Nicole Politto My Commission Expires: 10/17/25 ARCHITECT'S CERTIFICATION Architect's signature below is his assurance to Owner, concerning the payment herein applied for, that: (1) Architect has inspected the Work represented by this Application, (2) such Work has been completed to the extent indicated in this Application, and the quality of workmanship and materials conforms with the Contract Documents, (3) this Application for Payment accurately states the amount of Work completed and payment due therefor, and (4) Architect knows of no reason why payment should not be made. CERTIFIED AMOUNT................................................................. $4,400.00 (If the certified amount is different from the payment due, you should attach an explanation. Initial all the figures that are changed to match the certified amount.) ARCHITECT: By: [signature] Date: 10/08/2024 Neither this Application nor payment applied for herein is assignable or negotiable. Payment shall be made only to Contractor, and is without prejudice to any rights of Owner or Contractor under the Contract Documents or otherwise.