ࡱ> xzw%` 'bjbjNN .t,,,"k+(22222""""5"&*$,h.b+ +22%+"22""2& /K3!;+0k+]/IB]/]/++k+  MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALITY-WATER BUREAU REVOLVING LOAN AND OPERATOR CERTIFICATION SECTION DRINKING WATER REVOLVING FUND (DWRF) AND CLEAN WATER STATE REVOLVING FUNDS (SRF/SWQIF) REQUEST FOR DISBURSEMENT OF FUNDS THIS INFORMATION IS REQUIRED UNDER AUTHORITY OF PARTS 52, 53, AND 54, 1994 PA 451. PLEASE SEE OTHER SIDE FOR INSTRUCTIONS TO COMPLETE REQUEST A. Project #B. Request #C. Period Covered by Request ___________ to ___________ (M/D/Y) (M/D/Y)D. Request Type ( partial ( finalE. Recipients EINF. Loan AmountG. Recipients Name: Phone # Address: H. Recipients Bank Name: Phone # Address:  Account Name: ABA #Account # Special Instructions: I. Budget Items (round amounts to the nearest dollar)Approved Amount Incurred this PeriodApproved Amount Incurred to Date 1. PLANNING COSTS 2. USER CHARGE SYSTEM DEVELOPMENT COSTS 3. DESIGN ENGINEERING COSTS 4. LEGAL/FINANCIAL SERVICE FEES 5. ADMINISTRATIVE COSTS 6. BOND COUNSEL FEES 7. BOND ADVERTISEMENT COSTS 8. BID ADVERTISEMENT COSTS 9. CAPITALIZED INTEREST 10. LAND ACQUISITION/RELOCATION COSTS 11. LAND PURCHASE COSTS 12. CONSTRUCTION ENGINEERING COSTS 13. CONSTRUCTION COSTS (bid contracts) 14. CONSTRUCTION COSTS (force account) 15. EQUIPMENT COSTS 16. OTHER PROJECT COSTS 17. ADJUSTMENTS DUE TO OTHER FUNDING( ) 18. TOTAL AMOUNT INCURRED THIS PERIOD 19. TOTAL CUMULATIVE AMOUNT INCURRED TO DATE 20. AMOUNT PREVIOUSLY DISBURSED 21. AMOUNT REQUESTED FOR DISBURSEMENT I certify that I am an authorized representative of the recipient and am authorized to make the following certifications on behalf of the recipient: (i) there is no pending litigation or event which will materially and adversely affect the project, the prospects for its completion, or the recipients ability to make timely repayments on the obligation issued in connection with this project; (ii) the representations, warranties and covenants contained in the supplemental agreement for the obligations pursuant to which this request for disbursement is submitted continue to be true and accurate in all material respects as of the date hereof; (iii) to the best of my knowledge and belief, the costs above were incurred in accordance with the terms of the supplemental agreement and the application for assistance for this project; and (iv) the amount requested for disbursement represents the loan amount due, which has not previously been requested. Authorized Representative Name (Print or Type): _________________________________________________ Title: ________________________ Authorized Representative Signature (Original): ____________________________________________________ Date: ______________________ PLEASE RETURN THIS COMPLETED REQUEST TO THE ADDRESS SHOWN ON THE REVERSE SIDE(1/06) DRINKING WATER AND CLEAN WATER STATE REVOLVING FUNDS Instructions for Completing a Request for Disbursement of Funds A. Fill in the respective program project number that was assigned by the Michigan Department of Environmental Quality (DEQ). B. Identify the number of this disbursement request. C. Indicate the calendar period covered by this disbursement request. D. Check whether this is a partial or the final disbursement request. E. Fill in the recipients federal employer identification number (EIN). F. Fill in the loan amount as shown in the Order of Approval. G. Fill in the loan recipients (bond issuer) name, address, and telephone number. This information must match data on file with the DEQ; if changes have occurred, please inform your DEQ project manager in a separate letter accompanying this request. H. Fill in your banks name, address, telephone number, and ABA identifying number, the account name and number, and any special instructions for the wire transfer to that account. This information must match data on file with the DEQ; if changes have occurred, please inform your DEQ project manager in a separate letter accompanying this request. I. Recap approved eligible costs incurred to date for each budget item. Show the amount requested for the period covered by this request, and then the cumulative amount to date from project inception. Entries in this section must be rounded to the nearest dollar. If costs have been incurred for a budget item that was not shown in the DEQ Order of Approval, please inform your project manager in a separate letter accompanying this request. 1. Enter the costs invoiced and/or paid for planning (do not include costs of tangible assets such as pilot facilities and test wells). 2. Enter the costs invoiced and/or paid for services directly associated with the development and enactment of the municipalitys user charge system and any related ordinances. 3. Enter the costs invoiced and/or paid for project design work required prior to actual construction. 4. Enter the costs invoiced and/or paid for legal or financial services except costs associated with the issuance of bonds related to this project. 5. Enter the costs incurred for salaries and indirect costs of the water supplier or municipal employees involved in the project administration. 6. Enter the costs invoiced and/or paid for legal or financial services associated with the issuance of bonds related to this project. 7. Enter the costs invoiced and/or paid to publish legal notices related to the sale of bonds related to this project. 8. Enter the costs invoiced and/or paid to publish advertisements for bids for the project construction contracts. 9. Enter only the amount of capitalized interest invoiced and/or paid for the period covered by this request. 10. Enter the costs invoiced and/or paid for services related to compliance with the federal Uniform Relocation Assistance and Real Property Acquisition Policies Act (49 CFR Part 24). 11. Enter the costs invoiced and/or paid for the purchase of property which was deemed eligible and included in the Supplemental Agreement. 12. Enter the costs invoiced and/or paid for project construction engineering services. 13. Enter the costs invoiced and/or paid under the project construction contracts. 14. Enter the costs incurred for salaries and indirect costs of the water supplier or municipal employees involved in the project construction labor ($50,000 limit). 15. Enter the costs invoiced and/or paid for equipment purchased as part of this project. 16. Enter other costs invoiced and/or paid for miscellaneous items that were approved by the DEQ for inclusion in this project. If new items have been procured, please inform your project manager in a separate letter accompanying this request. 17. Enter adjustment which arises from reimbursements by other funding sources or the use of cash on hand. 18. Enter the sum of the amounts shown in Column 1 (Amount Incurred this Period). 19. Enter the sum of the amounts shown in Column 2 (Amount Incurred Cumulative to Date). 20. Enter the total amount of funds previously paid (Line 19 on the previous disbursement request). 21. Subtract Line 20 from line 19 to arrive at the Amount Requested for Disbursement. PLEASE NOTE: EXCEPT FOR REQUESTS #1 AND #2, YOU MAY SUBMIT NO MORE THAN ONE REQUEST FOR DISBURSEMENT DURING A CALENDAR MONTH. A SIGNED ORIGINAL (NO SIGNATURE STAMP) OF REQUEST #1 AND THE FINAL REQUEST MUST BE HAND-DELIVERED OR SUBMITTED BY MAIL (A FACSIMILE WILL NOT BE ACCEPTED). PLEASE ATTACH DOCUMENTATION TO SUPPORT THE INCURRED COSTS WITH EACH SUBMITTED FORM. 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