Laserfiche WebLink
Attachment F <br /> REQUEST FOR PAYMENT FORM <br /> Date : Contract #: <br /> Payment Request #: Project Area : _ <br /> To: Benjamin L . Nash , Government Analyst II <br /> Florida Department of Community Affairs <br /> Division of Housing and Community Development <br /> 2555 Shumard Oak Blvd , Rm . 250D <br /> Tallahassee , FL. 32399-2100 <br /> From : <br /> ( Recipient Name) <br /> (Office Address) <br /> Subject: Reimbursement Request for Contract Expenditure(s) <br /> Please process the following payment request. <br /> Item # Date of Item Description Amount Due <br /> Transaction <br /> Total Amount <br /> Contract Balance. <br /> Contract Beginning Balance <br /> Less Total Payments Requested <br /> From HCD <br /> Less This Warrant Amount <br /> Contract Balance After This Warrant <br /> Contract Administrator: Date : <br /> "Attach to this document all required backup documentation and/or receipts to verify the above charge(s). <br /> 25 <br />