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H TRUE COPY <br />CERTIFICATION ON LAST PAGE <br />RYAN L. BUTLER, CLERK <br />EXHIBIT D <br />FLORIDA INLAND NAVIGATION DISTRICT <br />ASSISTANCE PROGRAM <br />PAYMENT REIMBURSEMENT REQUEST FORM <br />PROJECT NAME: <br />PROJECT SPONSOR: <br />Amount of Assistance A. <br />Less Previous Total Disbursements B. <br />and Less Previous Total Retainage <br />Held Balance Available = <br />Funds Requested This Disbursement <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 ail 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 <br />Vendor Name and Date Cost <br />PROJECT #-- <br />BILLING <br />: <br />BILLING #: <br />Applicant FIND <br />Cost Cost <br />FIND - Form No. 90-14 (NOTE: Signature Required on Page 2) <br />Effective Date 7-30-02) <br />