20221026152642315Payroll Number: 9
Contractor:
STATEMENT OF NON-PERFORMANCE
White Rock Construction Inc.
Date:
I do hereby state that no persons were employed on the construction of
(H2 - Keller -Heavenly Phase 2
during the payroll period commencing on the day of 10/16/2022
ending on the
�day of 10/22/2022
(Signature of thg�ithorized Person)
Katie McCrosky, Secretary
(Name)
This statement is not required to be submitted until after the submission of the
initial payroll period.
10/26/2022