Laserfiche WebLink
Grantee's Certification of Payment Request <br /> I, <br /> (Print name of Grantee's Grant Manager designated in the Agreement) <br /> on behalf of , do hereby certify that: <br /> (Print name of Grantee/Recipient) <br /> 0 The disbursement amount requested is for allowable costs for the project described in Attachment A of <br /> the Agreement. <br /> 0 All costs included in the amount requested have been satisfactorily purchased, performed, received, and <br /> applied toward completing the project; such costs are documented by invoices or other appropriate <br /> documentation as required in the Agreement. <br /> D The Grantee has paid such costs under the terms and provisions of contracts relating directly to the project; <br /> and the Grantee is not in default of any terms or provisions of the contracts. <br /> Check all that apply: <br /> ❑ All permits and approvals required for the construction,which is underway, have been obtained. <br /> ❑ Construction up to the point of this disbursement is in compliance with the construction plans and permits. <br /> ❑ The Grantee's Grant Manager relied on certifications from the following professionals that provided <br /> services for this project during the time period covered by this Certification of Payment Request,and such <br /> certifications are included: <br /> Professional Service Provider(Name/License No.) Period of Service(mm/dd/yy—mm/dd/yy) <br /> Grantee's Grant Manager's Signature Grantee's Fiscal Agent <br /> Print Name Print Name <br /> Telephone Number Telephone Number <br /> DEP 55-223(11/15) <br /> DEP Agreement No.S0839,Attachment B,Page 2 of 3 <br />