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EXHIBIT D <br />FLORIDA INLAND NAVIGATION DISTRICT <br />ASSISTANCE PROGRAM <br />PAYMENT REIMBURSEMENT REQUEST FORM <br />PROJECT NAME: PROJECT #: <br />PROJECT SPONSOR: <br />BILLING #: <br />Amount of Assistance <br />Less Previous Total Disbursements <br />and Less Previous Total Retainage <br />Held Balance Available <br />Funds Reauested This Disbursement <br />A. <br />B. <br />Funds Requested C. <br />Less Retainage (-10% unless final) D. <br />Check Amount = <br />Amount of Assistance <br />Less Total Prior and Current <br />Payments Including all retainage <br />held (B+C) _ <br />= Balance Remaining <br />Expense Description <br />(Should correspond to <br />Cost Estimate Sheet <br />Categories in Exhibit "A") <br />SCHEDULE OF EXPENDITURES <br />Check No. Total Applicant FIND <br />Vendor Name and Date Cost Cost Cost <br />FIND - Form No. 90-14 (NOTE: Signature Required on Page 2) <br />Effective Date 7-30-02) <br />