HomeMy WebLinkAboutexhibit4Florida Department of State, Division of Library and Information Services
R.A. Gray Building, 600 South Bronough Street, Tallahassee, FL 32399-0250
Public Library Construction Grant Program
Payment Request #2
At least 60% of the construction costs must be expended before this payment request can be
submitted. Complete this form and submit along with the following items, or indicate that the
items are already on file with the Division.
Organization Name.
Project Number.
Project Name•
Required Document
On File With
the Division
Attached
1. Application and Certificate for Payment and
Continuation Sheet (ATA Documents G702 and G703
or its equivalent) showing at least 60% of the
construction completed.
I hereby certify that the information provided is accurate to the best of my knowledge; that all
provisions of the library construction guidelines and the grant agreement have been met; that
sufficient local matching funds have been disbursed, obligated, or are currently available, and at
least 60% of the construction costs have been expended.
Signature:
Signature:
Project Manager or Authorized Official Chief Financial Officer of Governing Body
Print/Type Name Print/Type Name
Title Title
Name of Agency Name of Agency
Date Date
Public Library Construction Grant Program
Payment Request #2 (DLIS/PLC03), Effective: 1/9/2003 Page 1 of 1