Laserfiche WebLink
ATTACHMENT B <br /> Disbursement Request Form <br /> Legislative Projects (Lp) Grants <br /> 1 . Grantee/Recipient Indian River County <br /> 2 Project Number LP0328 Date of Request <br /> 2 Disbursement Request Number Required Match % <br /> 3 . Disbursement Request Number <br /> 4 . Type of Request: Partial ❑ Fina ❑ <br /> 5 . Federal Employer Identification Number <br /> 6 . Mail ❑ EFT ❑ Send Remittance to : <br /> Disbursement Details <br /> (cumulative amounts rounded to the nearest dollar) <br /> 1 . Planning (attach invoices) $ <br /> 2 . Engineering (attach invoices) <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 32399=2400 <br /> DEP Agreement No . LP###, Attachment B , Page 1 of 3 <br />