LSJ CONSTRUCTION Subcontractor Payout Project: Main House Renovations #1009 Trade: Air Conditioning Subcontractor Atlanta Refrigeration Invoice # Phase # Requisition #01, 02 15-800 Original Contract Sum: Change Orders Submitted & Approved: New Change Orders: Total Work Contracted to Date: Total Work Completed to Date: Less Retainage: Total Payments Made to Date: Total Current Payment Due: I $28,189.05 Balance to Finish including Retainage: $0.00 Sales Tax Liability: January 4, 2011 Requisition #01, 02 Insurance ex i iration: March 26. 2011 $28,189.05 $0.00 $0.00 $28,189.05 100% $28.189.05 $0.00 a. Subcontractor/Supplier is liable, explaii install only / tax included in contract b. Non-resident Subcontractor/Supplier Bond Applicable: c. Use Tax to be paid by our company: $0.00 d. Shipping None Total Outlays for this contract incl. Sales or Use Tax: JEE approval attached YES NO X Submitted Bill Signed: Date: January 4. 2011 Approved by: Emad Signed: Date: $28.189.05 Invoice Attached YES NO X Approved by: Gary Signed: Date: January 4, 2011 Approved by. Signed. Date: EFTA01118389