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HomeMy WebLinkAboutSRF - Disbursement Request ffersonville Sewage 500 Quartermaster Ct., Suite 300 City Hall Jeffersonville, IN 47130 3. Contact Person: Peggy Wilder, Clerk-Treasurer 3a. Contact Phone No.: 4. Participant's Authorized Representative: Tom Galligan, Mayor 5. Authorized Representative's Phone No.: (812) 285-6400 6. Description of work for which claim is being made (service, fees, type of, etc.): Blanchel Terrace Combined Sewer Separation Project - Invoice #1 SRF - DISBURSEMENT REQUEST y-P.articipant: 1. ;1ailing Address: 1 a. SRF Loan Number: 2a. Request No.: WW06121002 5 (812) 285-6429 7. Contractor Team Contracting 7a. Address P. O. Box 237 Memphis, IN 47143 Amount Requested 1,.7-B.alance Available after this Disbursement............................ f \, $ 127,776 (Amount to Contractor) $ 9,800,000 $ 77,731 $ 127,776 (Amount to Contractor plus retainage: $ 9,664,493 8. 9. ()riginal Loan Amount: ............................... ................... ..... 10. Total Amount of Previous Disbursements .............................. 11. Amount of this Request.................................................... 1 3. Is a portion of the claim underlying this Request subject to retainage under I.C.36-1-12-14 or similar law? YES x NO 14. If yes, the retain age amount is ........................................... $ 12,776 (This amount will be sent to the retainage account set forth below and the remainder will be sent directly to the contractor identified above.) Name of Bank: Your Community Bank Retainage Account Number: 597006254 Routing Number: 283071827 1 5. Has the Participant paid the request and is now seeking reimbursement? YES NO x 16. Is any part of this claim a result of a change order? "If so, please attach the SRF change .order approval letter" 17. Is this the final payment to the contractor? YES NO x YES NO x The undersigned hereby certifies that this Request is true and correct, that the claim underlying this Request is 1egall: due (and is payable from SRF) in accordance with the Participant's Financial Assistance Agreement with the Authori .f\ ] 8. DATE 05/19/08 18a. AUTHORIZED REPRESENTATIVE SIGNATURE