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SIB Disbursement Form B <br />(Address of Borrower) <br />Invoice # <br />Date: <br />Draw/4: _ <br />SIB Loan: <br />Job/Project: <br />Voucher # Paid Date Warrant # Amount <br />Total of Invoice: <br />This is to certify that the work as evidenced by an appropriate invoice of actual production, as attached to justify the <br />above amounts, has been completed and in no way represents any degree of duplication of payments and that all costs <br />were incurred in accordance with the terms and conditions of the Agreements listed on the vouchers attached. <br />Date: <br />ut orize Representative <br />Date: <br />(Engineer) <br />aAK3:222226 I» <br />