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EXHIEIT D <br />SIB DISBURSEMENT <br />F®RMSA~B <br />SIB Dasburserrieut Foran A <br />(Address of Borrower) <br />TO: Ohio Department of Transportation <br />Office of Economic Development <br />1980 West Broad Street, 2nd Floor <br />Columbus, Ohio 43233 <br />Invoice # <br />Date: <br />Project: <br />D~ <br />aw #: SIB <br />Loan: <br />Payment Item Original Cost of <br />Project Previous Payments Amount Due this <br />Payment Balance Due to <br />Complete Project <br />Design <br />Engineering Design <br />Construction <br />(Specify <br /> <br /> <br /> <br /> <br />Net Total of <br />Invoice <br />Certification Statement: <br />I certify that I have checked and verified the attached detail for Partial Payment; that to the best of my knowledge and <br />belief it is a true and correct statement of work performed and/or materials supplied by the Contractor; that all work <br />and/or materials included in this partial payment has been inspected by me and/or my duly authorized representative <br />or assistants and that it had been performed and/or supplied in full accordance with requirements of the referenced <br />contract; and that partial payment claimed and requested is correctly computed on the basis of work performed and/or <br />material supplied to date. <br />Also, that each item for which payment is requested is a cost property payable costs of the loan proceeds in accordance <br />with the terms and conditions of this loan agreement and none of the items for which the payment is proposed to be <br />made has formed the basis for any payment theretofore made from the loan proceeds; that each item for which <br />payment is proposed to be made is or was necessary in connection with the Project, and each payee has submitted <br />appropriate waivers of any mechanics' or other liens and affidavit as required. <br />City/Council Village Project Engineer <br />Date: <br />City Manager/Mayor/Commissioner <br />ODOT Approved Date: <br />