HomeMy WebLinkAboutExhibit 17EX461T6
dice -of Capital improvements
Recioest for Advance Payment
Date
Grantee
j Grantee Vendor 'Number
(Fboera! tD Number)
Bond Series / Other
GOB Project Name & GOB Project Number
GOB Project Amount
Amount of Advance Requested
Reason For Requested Amount
Certification
1 hereby certify that this request is in compliance with the Office of Capita! improvements Building Better Communities
Bond Program Administrative Rules, Article ill Section IC(8) governing the request for advance payments. !also
certify that this advance shall be maintained in e separtee interest bearing account, that these funds will not be co -
mingled with other funds and that all interest Earned will be repaid to the County 1 further agree do account for this
advance within one (7) }rear of the approval date, indicates' below, and before .any subsequent.reimbursement requests
are submitted.
1
AUTHORIZED SIGNATURE
DATE
Administrative Use Only
J
Amount Approved
Authorized Signature Date