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