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EXHIBIT D <br />FLORIDA INLAND NAVIGATION DISTRICT <br />ASSISTANCE PROGRAM <br />PAYMENT REIMBURSEMENT REQUEST FORM <br />PROJECT NAME: <br />PROJECT SPONSOR: <br />Amount of Assistance <br />All Funds Previously Requested <br />Balance Available <br />Funds Requested <br />Less Retainage (-10% unless final) <br />Check Amount <br />Balance Available <br />Less Check Amount <br />Balance Remaining <br />Expense Description <br />(Should correspond to <br />Cost Estimate Sheet <br />Categories in Exhibit "B") <br />�c- <br />PROJECT NO.: <br />BILLING NO.: <br />SCHEDULE OF EXPENDITURES <br />Check No. Total <br />Vendor Name and Date Cost <br />Applicant <br />Cost <br />FIND <br />Cost <br />FIND - Form No. 90-14 <br />Effective Date 7-30-02) <br />(NOTE: Signature Required on Page 2) <br />