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J <br /> r <br /> ATTACHMENT B <br /> u <br /> Disbursement Request Form O ost� <br /> Legislative Projects (LP) Grants / <br /> 1 . Grantee/Recipient Indian River County n <br /> 2 Project Number LP0328 Y t '�'' , _X <br /> Date of Request 2 / 14 / 0 3 <br /> 11 - 1 <br /> 2 Disbursement Request Number 1 Required Match 96 <br /> 3 . Disbursement Request Number eel .1 <br /> 4 . Type of Request: Partial Final ❑ / , _ <br /> 5 . Federal Employer Identification Number 59 - 6000674 n 1 T,lr 1 f r <br /> J� <br /> 6 . Mail ❑ EFT ❑ Send Remittance to : / n <br /> INDIAN RIVER COUNTY UTILITIES <br /> 1840 25th STREET <br /> VERO BEACH , FL 32960 <br /> Disbursement Details <br /> (cumulative amounts rounded to the nearest dollar) <br /> 1 . Planning (attach invoices) $ <br /> 2 . Engineering (attach invoices) $ 3 9 17 9 . 0 0 <br /> 3 . Construction and Demolition (attach pay estimates) <br /> 4 . Technical Services during Construction (attach invoices) <br /> 5 . Other (must be specified in agreement) <br /> 6 . Total cumulative to date $ <br /> 7 . Disbursements previously requested $( ) <br /> 8 . Amount requested for disbursement $ <br /> (Line 6 minus line 7) <br /> * * SUBMIT ONE ORIGINAL COPY OF THIS FORM AND SUPPORTING DOCUMENTATION TO: * * <br /> Florida Department of Environmental Protection <br /> Bureau of Water Facilities Funding MS 3505 <br /> 2600 Blair Stone Road <br /> Tallahassee, Florida 323994400 <br /> DEP Agreement No. LP###, Attachment B , Page 1 of 3 <br />