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c : ? OPWC FUNDS DISBURSEMENT PROGRESS: ? Appendix E - Page 2 Disbursement Request #. Is this the final request for disbursement of OPWC funds? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If the answer is YES, skip to the section entitled "FINAL DISBURSEMENT REQUEST and PROJECf COMPLETION REPORT". N) Total project costs claimed as part of this draw (Total in G(3)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O) DisbursementRatio ............................................................................................ P) Amount of OPWC funds hereby requested for Disbiusement (N x O) (Becomes H(3)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO $ % $ FINAL DISBURSEMENT REQUEST and PROJECT COMPLETION REPORT: Project Completion Date _/_/_ By completing this section the subdivision certifies that the project is completed and no additional invoices will be submitted to the OPWC. Q) Total project costs (G(2) +G(3)) [if G(2) + G(3) > G(1) use the amount on G(1)] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ R) Subdivision Peroentage Participation Level (if cost overrun, percentage does not apply) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31% S) Subdivision minimum dollar contribution (QxR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ '1) Subdivision costs paid to date (Total in L(2)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Ln Total still owed toward Local Share (S-T) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ V) Total project costs claimed as part of this draw(Total in G (3)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ V) Total still owed toward Local Share (L) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 7Q Amount of OPWC funds hereby requested for Disbursement (V-V) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ (Becomes H(3)) Constiucrion funds currendy held in escrow by the subdivision and not reported on the previous page . . . . . . . . . . . . . . . . . . . . . . . . . . $ Total in H(4) (sum of H(2) + in H(1) lrefer to PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Pinject, have been completed in a satisfactory manner, and are otherwise in accord with the temis and conditions of the Agreement. This request reflects project completion at an estimated %. Gary Durbin/City Engineer Date Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Putsuant to Section 6(b) and 6(c) of the Agreement, the undetsigned Cluef Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project, or, in the case of a final disbuisement request, the amount entered at Line V of this Appendix E. The undersigned further ceRify that: 1) Each item of project cost documentation attached hereto is properly payable out of the Local Transportation Improvements Fund in accordance with the teims and conditions of the Agreement, and none of the items for which payment is requested has focmed the basis of any payment heretofore made from the State Capital Improvements Fund; 2) Each item for which payment is requested hereunder is or was necessary in connection with the performance of the project; 3) In the event that any of the money disbutsed to the Recipient pursuant to ttris request is to be used to pay Project costs based on an invoice submitted by a contractor of which the RecipienYs share is yet to be paid, the Recipient shall expend such money to pay such contractor for the Project costs within twenty-four (24) hours after receipt thereof. Recipient shall hold such money uninvested pending payment to the contractor; 4) This statement and attachments hereto shall be conclusive as evidence of the facts and statements set forth herein and shall constitute full wanant, protection, and authority to the Director for any actions taken puisuant hereto; and 5) T'his document evidences the approval of the undersigned Chief Executive Officer and Chief Fiscal Officer of each payment hereby requested and authorized. IN WITNESS WHEREOF, the undersigned have executed this Disbursement Request Form and Certification as of this day of , 20 Note: All signatures must be original and in ink. Carrie Copfer/Finance Director CFO Phone: ( ) Hon. Thomas E. O'Grady/Mayor