HomeMy WebLinkAboutexhibit5Florida Department of State, Division of Library and Information Services
R.A. Gray Building, 500 South Bronough Street, Tallahassee, FL 32399.0250
Public Library Construction Grant Program
Payment Request #3
100% 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.
Certificate of Substantial Completion (AIA
Document G704).
2.
Application and certificate for Payment and
Continuation Sheet (AIA Documents G702 & G703
or its equivalent). The G702 form must show that all
construction funds have been expended, and must
show a zero balance on line 9.
1 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
10D% of the construction costs have been expended.
Signature:
Signature:
Project Manager or Authorized Official Chief Financial Officer of Governing Body
Print/Type Name
Title
Print/Type Name
Title
Name of Agency Name of Agency
Date Date
Public Library Construction Grant Program
Payment Request 43 (DLIS/PLC04), Effective: Page 1 of 1