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Subdivision Name: City of Lakewood Cuyahoga County <br />Project Name: Watermain Replacement 2016 <br />OPWC Control No.: CA 16S (LOAN) <br />Project Manager: Mark Papke, P.E./Project Manager <br />Appendix E - Page 3 <br />Disbursement Request N <br />CONTRACTOIMNDOR PAYEE IDENTIFICATION: <br />Set forth the appropriate portion(s) of this Disbursement Request amount (all or part of the amount from H(3)) that is to be paid to each of the <br />contractors /vendors (or Subdivision) identified below, and as are supported through accompanying copies of invoices or other evidence of expense. <br />t) AMOUNT TO BE PAID CONTRACTORfVENDOR BY the OPWC .................. ............................... $ <br />PAYEE: <br />Address: <br />Phone: ( ) <br />Federal Tax Ill #: <br />2) AMOUNT TO BE PAID CONTRACTORfVENDOR BY the OPWC .................. ............................... S <br />PAYEE: <br />Address: <br />Phone: ( ) <br />Federal Tax ID #: <br />3) AMOUNTTO BE PAID CON'TRACTORIVENDOR BY the OPWC .................. ............................... $ <br />PAYEE: <br />Address: <br />Phone: ( ) <br />Federal Tax ID #: <br />d) AMOUNT TO BE PAID CONTRACTORIVENDOR BY the OPWC .................. ............................... $ <br />PAYEE: <br />Address: <br />Phone: ( ) <br />Federal Tax ID #: <br />