Packet: Tiffin Regular City Council Meeting (02/17/2026)

SWORN STATEMENT TO OWNER AND MIRON CONSTRUCTION CO., INC. State of Iowa County of Linn John Ilten (Name) being first duly sworn, under oath says that he/she is President (Title) of Iltens Inc that has a PSA dated August 21, 2025, with Miron Construction Co., Inc. for HVAC (Work Type) on the City of Tiffin Community Recreation Center Project, and that: For the purposes of this Payment Application, certain Subcontractor and/or Supply Agents have contracted with Iltens Inc to furnish labor and/or materials on the Project. That there is due and to become due Iltens Inc and them, respectively, the amounts set forth opposite the names on the Payment Application Form for labor and/or materials as listed. That this statement and the attached Payment Application Form are full, true and complete statements of all such Subcontractor and/or Supply Agents, the amounts paid and the amounts due or to become due to Iltens Inc and each Subcontractor and/or Supply Agent listed. Signed: [Signature] Subscribed and sworn to before me this 15 day of Dec 2025 Signed: Alison Bell Notary Public ALISON J BELL Notarial Seal - Iowa Commission Number 847687 My Commission Expires Apr 26, 2026 My Commission expires: My Commission Expires Apr 26, 2026 Notary Seal or Stamp: THIS NOTARIZED FORM MUST BE ATTACHED TO EACH PAYMENT APPLICATION FORM AND RETURNED WITH ALL APPLICABLE SIGNED AND NOTARIZED LIEN WAIVERS. FAILURE TO ABIDE BY THESE TERMS WILL RESULT IN DELAY OR REDUCTION IN REQUESTED PAYMENT.