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Menomonie, WI 54751-5436N4449 469th StreetPEMBER COMPANIES, INC.PEMBER COMPANIES, INC.REQUEST FOR PAYMENT11/30/2021Invoice date: Period ending date:12731To:From:11/30/20211245 Hwy. 96 W.Arden Hills, MN 55112Invoice:City of Arden HillsProject: 21-0232-01 ARDEN HILLS, MN - HAMLINE AVEREQUEST FOR PAYMENT:$526.50$120,812.58$0.00$142,986.15$143,512.65$10,091.00$133,421.65Less Previous Requests:Remaining Contract to Bill:Original Contract Amount:Net Change Orders:Revised Contract Amount:Contract Completed to Date:Date: ________________________________________By: __________________________________________My commission expires:Notary PublicSubscribed and sworn to before me this ______ day of _____________,__________CONTRACTOR:I hereby certify that the work performed and the materials supplied to date, as shown on the above represent the actual value of the accomplishment under the terms of theContract (and all authorized changes thereof) between the undersigned and the City of Arden Hills relating to the above referenced project. I also certify that the contractor haspaid all amounts previously billed and paid by the owner.Current Request for Payment: $22,173.57State Of Wisconsin County Of DunnRetainage:PAYMENT RECOMMENDED: PAYMENT APPROVED :Engineer SignaturePrinted Name and TitleDate:Owner SignatureDate:Printed Name and TitleNovember 30, 2021PEMBER COMPANI_______________________OR:ovember30 2021Jordan HorejsiDecember 2, 2021Jordan HorejsiDigitally signed by Jordan HorejsiDN: C=US, E=jhorejsi@hrgreen.com, O=HR Green, OU=Project Manager, CN=Jordan HorejsiDate: 2021.12.02 14:41:04-06'00'