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ATTACHMENT B
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Disbursement Request Form O ost�
Legislative Projects (LP) Grants /
1 . Grantee/Recipient Indian River County n
2 Project Number LP0328 Y t '�'' , _X
Date of Request 2 / 14 / 0 3
11 - 1
2 Disbursement Request Number 1 Required Match 96
3 . Disbursement Request Number eel .1
4 . Type of Request: Partial Final ❑ / , _
5 . Federal Employer Identification Number 59 - 6000674 n 1 T,lr 1 f r
J�
6 . Mail ❑ EFT ❑ Send Remittance to : / n
INDIAN RIVER COUNTY UTILITIES
1840 25th STREET
VERO BEACH , FL 32960
Disbursement Details
(cumulative amounts rounded to the nearest dollar)
1 . Planning (attach invoices) $
2 . Engineering (attach invoices) $ 3 9 17 9 . 0 0
3 . Construction and Demolition (attach pay estimates)
4 . Technical Services during Construction (attach invoices)
5 . Other (must be specified in agreement)
6 . Total cumulative to date $
7 . Disbursements previously requested $( )
8 . Amount requested for disbursement $
(Line 6 minus line 7)
* * SUBMIT ONE ORIGINAL COPY OF THIS FORM AND SUPPORTING DOCUMENTATION TO: * *
Florida Department of Environmental Protection
Bureau of Water Facilities Funding MS 3505
2600 Blair Stone Road
Tallahassee, Florida 323994400
DEP Agreement No. LP###, Attachment B , Page 1 of 3
Authorized Representative 's Certification
of Disbursement Request
i,
Kenneth R Ma h
(name of Authorized Representative designated in the agreement)
on behalf of Indian River County , do hereby certify that:
(name of Grantee/Recipient)
1 . The disbursement amount requested on page 1 of this form is for allowable costs for the project described in the
agreement.
2 . Materials, labor, equipment, and/or services representing costs included in the amount requested have been
satisfactorily purchased, performed or received, and applied toward completing the project; such costs are
documented by invoices or other appropriate documentation which are filed in the Project Sponsor' s permanent
records.
3 . The Project Sponsor is required to pay such costs under the terms and provisions of contracts relating directly to the
project, and the Project Sponsor is not in default of any terms or provisions of the contracts .
4. All funds received to date have been applied toward completing the project.
5 . All permits and approvals required for the construction which is and ay have been obtained.
( Signature of Autho ' Re resentative)
K nneth R . Macht , Chairman
March 4 , 2003
(Date)
Indian River Co . Approved Date
Administration y�
l ' tilitic � 1 OL
Budget 3 � b �
Legal f
Risk INtanager
DEP Agreement No . LP###, Attachment B , Page 2 of 3
Engineer's Certification
of Disbursement Request
I, M I C H A EL C . " TCO TCO k ! 5 5 , being the Professional Engineer retained by
(name of Professional Engineer)
lAtil 11 veA r ft tJrl 0TH / VCS , am responsible for overseeing construction of the
(name of Grantee/Recipient)
project described in the Agreement and do hereby certify that:
1 . Equipment, materials, labor, and services represented by the construction invoices have been satisfactorily purchased
or received and applied to the project in accordance with construction contract documents filed with and previously
approved by the Department of Environmental Protection ;
2. Payment is in accordance with construction contract provisions ;
3 . Adequate construction supervision is being provided to assure compliance with construction requirements and
Florida Administrative Code Rule 62-600 or Rule 62-604, as appropriate;
4 . Construction up to the point of this disbursement is in compliance with the contract documents ;
5 . All changes, additions, or deletions to the construction contract(s) have been documented by change order and all
change orders have been submitted to the Department; and
6 . All additions or deletions to the Project which have altered the Project' s performance standards, scope, or purpose
(since issue of the pertinent Department permit) have been identified in writing to the Department or are identified
and attached hereto . (An attachment is included) .
Yes No ❑
Signature of Professional Engineer
co �,�� r1 UTiC / r/,�5'
Firm or Affiliation
3 - 62 - a 3 3gs/ L
(Dau) (P.E. Number)
Indian River Co . Approved Date
Administration
Utilities 1 1/
Budget l /3
Risk Manager
DEP Agreement No . LP###, Attachment B , Page 3 of 3
ATTACHMENT B
Disbursement Request Form
Legislative Projects (Lp) Grants
1 . Grantee/Recipient Indian River County
2 Project Number LP0328 Date of Request
2 Disbursement Request Number Required Match %
3 . Disbursement Request Number
4 . Type of Request: Partial ❑ Fina ❑
5 . Federal Employer Identification Number
6 . Mail ❑ EFT ❑ Send Remittance to :
Disbursement Details
(cumulative amounts rounded to the nearest dollar)
1 . Planning (attach invoices) $
2 . Engineering (attach invoices)
3 . Construction and Demolition (attach pay estimates)
4. Technical Services during Construction (attach invoices)
5 . Other (must be specified in agreement)
6 . Total cumulative to date $
7. Disbursements previously requested $( )
8 . Amount requested for disbursement $
(Line 6 minus Line 7)
* * SUBMIT ONE ORIGINAL COPY OF THIS FORM AND SUPPORTING DOCUMENTATION TO: **
Florida Department of Environmental Protection
Bureau of Water Facilities Funding MS 3505
2600 Blair Stone Road
Tallahassee, Florida 32399=2400
DEP Agreement No . LP###, Attachment B , Page 1 of 3
Authorized Representative 's Certification
of Disbursement Request
W . Erik Olson
(name of Authorized Representative designated in the agreement) ,
on behalf of Indian River County , do hereby certify that:
(name of Grantee/Recipient)
1 . The disbursement amount requested on page 1 of this form is for allowable costs for the project described in the
agreement.
2 . Materials , labor, equipment, and/or services representing costs included in the amount requested have been
satisfactorily purchased, performed or received, and applied toward completing the project; such costs are
documented by invoices or other appropriate documentation which are filed in the Project Sponsor' s permanent
records.
3 . The Project Sponsor is required to pay such costs under the terms and provisions of contracts relating directly to the
project, and the Project Sponsor is not in default of any terms or provisions of the contracts .
4. All funds received to date have been applied toward completing the project.
5 . All permits and approvals required for the construction which is underway have been obtained .
( Signature of Authorized Representative)
W . Erik Olson , Utilities Director
(Date)
DEP Agreement No . LP###, Attachment B , Page 2 of 3
Engineer's Certification
of Disbursement Request
I, , being the Professional Engineer retained by
(name of Professional Engineer)
, am responsible for overseeing construction of the
(name of Grantee/Recipient)
project described in the Agreement and do hereby certify that:
1 . Equipment, materials, labor, and services represented by the construction invoices have been satisfactorily purchased
or received and applied to the project in accordance with construction contract documents filed with and previously
approved by the Department of Environmental Protection;
2. Payment is in accordance with construction contract provisions;
3 . Adequate construction supervision is being provided to assure compliance with construction requirements and
Florida Administrative Code Rule 62-600 or Rule 62-604, as appropriate;
4. Construction up to the point of this disbursement is in compliance with the contract documents ;
5 . All changes, additions, or deletions to the construction contract(s) have been documented by change order and all
change orders have been submitted to the Department; and
6. All additions or deletions to the Project which have altered the Project' s performance standards, scope, or purpose
(since issue of the pertinent Department permit) have been identified in writing to the Department or are identified
and attached hereto. (An attachment is included) .
Yes ❑ No ❑
Signature of Professional Engineer
Firm or Affiliation
(Date) (RE. Number)
Indian River Co . Approved Gate
:Administration
Ctilitics t
aIT
Budget
Risk Manager
DEP Agreement No . LP###, Attachment B , Page 3 of 3