Payroll Report_____________

Contract No.

STATEMENT OF NON-PERFORMANCE

Name of Contractor:

I do hereby state that no persons from this firm were employed on the construction of the Project No.	located at	on the

project during the payroll period commencing on the	day of

and ending the day of	2003

Company Name

Authorizing Signature

Title

Lyn Daffan

2003-05-19

Joe R.Jones Construction,Inc