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C,.,I0 PUBLIC WORKS COMMISSIk.,,., ? APPENDIX E- DISBUR5EMENT REQUEST FORM AND CERTIFICATION DISBURSEMENT REQUEST NUMBER: STATEMENT REQUESTING THE DISBURSEMENT OF FUNDS FROM THE LOCAL TRANSPORTATION IMPROVEMENT FUND PURSUANT TO SECTION 4 OF THE PROJECT AGREEMENT (the "Agreement") EXECUTED BETWEEN THE DIRECTOR OF THE OHIO PUBLIC WORKS COMMISSION (the "Director") AND The City of North Olmsted, 035-56882, Cuyahoga County (the "Recipient"), DATED July lst, 2006, FOR THE SOLE AND EXPRESS PURPOSE OF FINANCING THE CAPITAL IlvIPROVEMENT PROJECT DEFINED AND DESCRIBED IN APPENDIX A OF THE AGREEMENT (the "Project") AND NAMED AND NLTMBERED AS Great Northern Blvd. Reconstruction (NOMBL to Country Club), CAR04. EXPENDITURES PROGRESS: (1) (2) (3) (4) AS PER PAID PRIOR AS PART OF PAID TO DATE AGREEMENT TO THIS DRAW THIS DRAW (Column 2+ 3) A) Project Engineering Costs 1) Preliminary Engineering $0 $ $ $ 2) Final Design $0 $ $ $ 3) Other Engineering Services $70,000 $ $ $ B) Acquisition Expenses 1) Land $0 $ $ $ 2) Right-of-Way $0 $ $ $ C) Construction Costs $1,309,485 $ $ $ D) Equipment Costs $0 $ $ $ E) Other Direct Expenses $0 $ $ $ F) Contingencies $130,949 $ N/A $ N/A $ N/A G) Totals $1,510,434 $ $ $ FINANCING PROGRESS: (1) (2) (3) (4) AS PER USED PRIOR AS PART OF USED TO DATE AGREEMENT TO THIS DRAW THIS DRAW (Column 2+ 3) R) OPWC Funds $1,040,434 $ $ $ n Local Share 1) In-kind Contributions $0 $ $ $ 2) Public Revenues $270,000 $ $ $ 3) Private Revenues $0 $ $ $ K) Other Public Revenues 1) ODOT $200,000 $ $ $ 2) FmHA $0 $ $ $ 3) OEPA $0 $ $ $ 4) OWDA $0 $ $ $ 5) CDBG $0 $ $ $ 6) Other $0 $ $ $ L) Total Local and Other Public Revenues $470,000 $ $ $ 1Vn Totals ( H+L for each column ) $1,510,434 $ $ $ [NOTE: Column totals for Line M must be equal to the column totals for Line G.]