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Page 5 of 5 <br />1.. List of all subcontractors, laborers, materialmen and suppliers who have not been <br />paid from the payment received from the last Pay Request and the reason why <br />they were not paid (attach additional pages as necessary): <br />2. List of all subcontractors, laborers, materialmen and suppliers for which a signed <br />release of lien form (partial or final as applicable) is not included with this Pay <br />Request, together with an explanation as to why the release of lien form isnot <br />included (attach additional pages as necessary): <br />t <br />00622 =.Contractor's Application for Payment -.03-10 rev. <br />00622-5 <br />PAPublic WorksW NGINEERING DIVISION PROJECTSX17361RC Health Department Roof Replacement Project\1-Admin%id DocumentsWaster Contract Documentst00622 <br />Contractor's Apprication for Payment - 0340 rev.doc Rev. 05/01 <br />