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(--) A true copy of the applicable purchase order for the repair or replacement; <br />(_j Bills of sale for any component of the repair or replacement for which a bill of <br />sale may be delivered; andior <br />(___) A true copy of the Payee's statement or invoice. <br />4. Please disburse the following amount to the following Payee (if more than one Payee, <br />please attach additional pages hereto setting forth the following information): <br />Payee: <br />Amount:- <br />Address:- <br />Invoice <br />mount:Address:Invoice No.: <br />5. To induce the County to approve this Requisition and authorize the Capital Reserve <br />Account Agent to disburse funds held in the Capital Reserve Account, the undersigned certifies <br />that there are no outstanding construction liens against the Facility. <br />6. The following constitutes an itemized list of attachments to this certificate (if applicable): <br />(a) Contractor's Application for Payment (AIA Forms G702 and 0703). <br />(b) Architect's Certificate (AIA Forms G702 and G703). <br />[Remainder of page intentionally left blank.] <br />D-2 <br />