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ATTACHMENT B <br />Disbursement Request Package <br />Legislative Projects (LP) Grants <br />I. <br />2. <br />3. <br />4. <br />5. <br />6. <br />Grantee/Recipient INDIAN RIVER COUNTY <br />Project Number LP6822 Date of Request <br />Disbursement Request Number Required Match % <br />Type of Request: Partial ❑ Final ❑ <br />Federal Employer Identification Number <br />Mail ❑ EFT ❑ Send Remittance to: <br />Disbursement Details <br />(cumulative amounts rounded to the nearest dollar) <br />1. Professional Services (attach invoices) <br />2. Construction and Demolition (attach invoices) <br />3. Equipment (attach invoices) <br />4. Land (attach invoices) <br />5. Other (list - must be specified in agreement) <br />6. Total cumulative to date $ <br />7. Disbursements previously requested $( <br />8. Amount requested for disbursement (line 6 minus line 7) $ <br />Requests for Invoices already Paid: Requests for Invoices not yet Paid: <br />1) Copy of Invoice 1) Copy of Invoice <br />2) Proof of Payment 2) Advance Payment Justification (one per quarter) <br />3) Advance Payment— Interest Earned (after initial advance) <br />*If prior Disbursement Request was requested by invoices without proof of payment documentation, proof of the <br />prior payment will be required before this request can be disbursed. <br />** SUBMIT ONE ORIGINAL COPY OF THIS FORM AND SUPPORTING DOCUMENTATION TO: ** <br />Florida Department of Environmental Protection <br />Bureau of Water Facilities Funding MS 3505 <br />2600 Blair Stone Road <br />Tallahassee, Florida 32399-2400 <br />DEP Agreement No. LP6822, Attachment B, Page I of 3 <br />