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~ : r. <br />SIB Disbursement Form 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 />Draw #:_ <br />SIB 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 <br />and belief it is a true and correct statement of work performed and/or materials supplied by the Contractor; that all <br />work and/or materials included in this partial payment has been inspected by me and/or my duly authorized <br />representative or assistants and that it had been performed and/or supplied in full accordance with requirements of <br />the referenced contract; and that partial payment claimed and requested is correctly computed on the basis of work <br />performed and/or 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 <br />accordance with the terms and conditions of this loan agreement and none of the items for which the payment is <br />proposed to be made has formed the basis for any payment theretofore made from the loan proceeds; that each item <br />for which payment is proposed to be made is or was necessary in connection with the Project, and each payee has <br />submitted appropriate waivers of any mechanics' or other liens and affidavit as required. <br />Date: <br />City/CouncilNillage Project Engineer <br />Date: <br />City Manager/Mayor/Commissioner <br />ODOT Approved Date: <br />«AK3:222228 1» <br />