Packet: Tiffin Regular City Council Meeting (05/19/2026)

APPLICATION AND CERTIFICATE FOR PAYMENT To (OWNER): Miron Construction P.O. Box 509 Neenah, WI 54957-0509 Project: Tiffin Community Recreation Ce Miron Application No: 1 Invoice No: 25590 Period To: 4/23/2026 From: Appleby & Horn Tile Co. 128 31st St. NE Cedar Rapids, IA 52402 Via (Architect): Architect's Project No: 250120 Contract Date: CONTRACTOR'S APPLICATION FOR PAYMENT: <table> <tr> <th>CHANGE ORDER SUMMARY</th> <th>ADDITIONS</th> <th>DEDUCTIONS</th> </tr> <tr> <td>Approved previous months</td> <td>0.00</td> <td>0.00</td> </tr> <tr> <td>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 change by change orders</td> <td colspan="2">0.00</td> </tr> </table> Application is made for payment, as shown below, in connection with the Contract. Continuation Sheet is attached. 1. ORIGINAL CONTRACT SUM $ 37,673.00 2. Net change by Change Orders $ 0.00 3. CONTRACT SUM TO DATE (LINE 1+/-2) $ 37,673.00 4. TOTAL COMPLETED & STORED TO DATE (Column G on Continuation Sheet) $ 5,665.00 5. RETAINAGE $ 283.25 6. TOTAL EARNED LESS RETAINAGE $ 5,381.75 (Line 4 less Line 5) 7. LESS PREVIOUS CERTIFICATES FOR PAYMENT $ 0.00 (Line 6 from prior Certificate) 8. SALES TAX $ 0.00 9. CURRENT PAYMENT DUE $ 5,381.75 10. BALANCE TO FINISH, PLUS RETAINAGE $ 32,291.25 (Line 3 less Line 6) 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 payment received from the Owner, and that current payment shown herein is now due. CONTRACTOR: Appleby & Horn Tile Co. By: [signature] Date: 4/23/26 ARCHITECT'S CERTIFICATE FOR PAYMENT In accordance with the Contract Documents, based on on-site observations and the data comprising the above application, the Architect certifies to the Owner that to the best of the Architect's knowledge, information and belief the work has progressed as indicated, the quality of the Work is in accordance with the Contract Documents, and the Contractor is entitled to payment of the AMOUNT CERTIFIED. AMOUNT CERTIFIED.............................................$ (Attach explanation if amount certified differs from the amount applied for.) ARCHITECT: By: [signature] Date: [blank] This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herein. Issuance, payment and acceptance of payment are without prejudice to any rights of the Owner or Contractor under this Contract. State of: Iowa County of: Linn Subscribed and sworn to before me this 23 day of Apr. 1, 2026 Notary Public: My Commission expires: [stamp] SHERYL GLEW Commission Number 180910 My Commission Expires 8/28/20