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Grantee's Certification of Payment Request <br /> 1, _ ,on behalf of <br /> (Print name of Grantee's Grant Manager designated in the Agreement) <br /> ,do hereby certify for <br /> (Print name of Grantee) <br /> DEP Agreement No. and Payment Request No. that: <br /> 0 The disbursement amount requested is for allowable costs for the project described in Attachment A of the Agreement. <br /> 0 All costs included in the amount requested have been satisfactorily purchased,performed,received,and applied toward completing <br /> the project;such costs are documented by invoices or other appropriate documentation as required in the Agreement. <br /> El The Grantee has paid such costs under the terms and provisions of contracts relating directly to the project;and the Grantee is not in <br /> 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 services for this project during <br /> the time period covered by this Certification of Payment Request,and such 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 Signature <br /> Print Name Print Name <br /> Telephone Number Telephone Number <br /> DEP Agreement No.NS027,Exhibit D,Page 2 of 5 <br />