HomeMy WebLinkAboutExhibit 5EXHIBIT D
FLORIDA INLAND NAVIGATION DISTRICT
ASSISTANCE PROGRAM
PAYMENT REIMBURSEMENT REQUEST FORM
PROJECT NAME:
PROJECT SPONSOR:
Amount of Assistance
All Funds Previously Requested
Balance Available =
Funds Requested
Less Retainage (-1 O% unless final)
Check Amount
Balance Available
Less Check Amount
Balance Remaining =
PROJECT NO.:
BILLING NO.:
SCHEDULE OF EXPENDITURES
Expense Description Check No. Total Applicant FIND
(Should correspond to Vendor Name and Date Cost Cost Cost
Cost Estimate Sheet
Categories in Exhibit "B")
FIND - Form No. 90-14 (NOTE: Signature Required on Page 2)
Effective Date 7-30-02)
FIND - Form No. 90-14
Page Two
EXHIBIT D (CONTINUED)
SCHEDULE OF EXPENDITURES
Expense Description Check No, Total Applicant AND
(Should correspond to Vendor Name and Date Cost Cost
Cost Estimate Sheet
Categories in Exhibit "B")
Cost
Certification for Reimbursement: I certify that the above expenses were necessary and reasonable
for the accomplishment of the approved project and that these expenses are in accordance with
Exhibit "B" of the Project Agreement. *
Project Liaison Date
*S. 837.06 Florida Statutes, False official statements. - Whoever knowingly makes a false statement in
writing with the intent to mislead a public servant in the performance of his or her official duty shall be
guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775,083 F.S.
FIND - Form No. 90-14
Effective Date 7-30-02)