HomeMy WebLinkAboutPayment Reimbursement Request FormEXHIBIT D
FLORIDA INLAND NAVIGATION DISTRICT
ASSISTANCE PROGRAM
PAYMENT REIMBURSEMENT REQUEST FORM
PROJECT NAME: PROJECT NO.:
PROJECT SPONSOR: BILLING NO.:
Amount of Assistance
A!I Funds Previously Requested
Balance Available
Funds Requested
Less Retainage (-10% unless final) �r
Check Amount
Balance Available
Less Check Amount
Balance Remaining
Expense Description
(Should correspond to
Cost Estimate Sheet
Categories in Exhibit "B")
SCHEDULE OF EXPENDITURES
Check No. Total Applicant FIND
Vendor Name and Date Cost Cost Cost
FIND - Form No. 90-14 (NOTE: Signature Required on Page 2)
Effective Date 7-30-02)
FIND - Form No. 90-14
Page Two
Expense Description
(Should correspond to
Cost Estimate Sheet
Categories in Exhibit "B")
EXHIBIT D (CONTINUED)
SCHEDULE OF EXPENDITURES
Check No. Total
Vendor Name and Date Cost
Applicant FIND
Cost
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)