HomeMy WebLinkAboutexhibit6Florida 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 #4
All construction costs must be expended and the project completed 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.
Audit in compliance with Section 215.97, Florida
Statutes, and Chapter 10.550, Rules of the Auditor
General.
2.
Library Construction Closeout Report (form
DLIS/PLCO6).
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; and that the
construction project has been completed.
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 #4 (DLIS/PLC05), Effective: 1/9/2003 Page 1 of 1