HomeMy WebLinkAboutExhibit 4ATTACHMENT B
Disbursement Request Package
Legislative Projects (LP) Grants
1. Grantee/Recipient CITY OF MIAMI
2. Project Number LP8949. Date of Request
3. Disbursement Request Number Required Match %
4. Type of Request: Partial ❑ Final ❑
5. Federal Employer Identification Number
6. Mail ❑ EFT ❑ Send Remittance to:
Disbursement Details
(cumulative amounts rounded to the nearest dollar)
I. Professional Services (attach invoices)
2. Construction and Demolition (attach invoices)
3. Equipment (attach invoices)
4. Land (attach invoices)
5. Other (list - must be specified in agreement)
6. Total cumulative to date
7. Disbursements previously requested
8. Amount requested for disbursement (line 6 minus line 7)
$(
Requests for Invoices already Paid: Requests for Invoices not yet Paid:
1) Copy of invoice 1) Copy of Invoice
2) Proof of Payment 2) Advance Payment Justification (one per quarter)
3) Advance Payment — Interest Earned (after initial advance)
*If prior Disbursement Request was requested by invoices without proof of payment documentation, proof of the
prior payment will be required before this request can be disbursed.
** SUBMIT ONE ORIGINAL COPY OF THIS FORM AND SUPPORTING DOCUMENTATION TO: **
Florida Department of Environmental Protection
Bureau of Water Facilities Funding MS 3505
2600 Blair Stone Road
Tallahassee, Florida 32399-2400
DEP Agreement No. LP8949, Attachment B, Page 1 of 3
t,
Grant Manager's Certification
of Disbursement Request
(name of Grantee's Grant Manager designated in the Agreement)
on behalf of , do hereby certify that:
(name of Grantee/Recipient)
1. The disbursement amount requested on Page 1 of this form is for allowable costs for the project described in the
Agreement
2. Materials, labor, equipment, and/or services representing costs included in the amount requested have been
satisfactorily purchased, performed or received, and applied toward completing the project; such costs are
documented by invoices or other appropriate documentation which are filed in the Grantee's permanent records;
3. The Grantee is required to pay such costs under the terms and provisions of contracts relating directly to the project;
and the Grantee is not in default of any terms or provisions of the contracts;
4. All funds received to date have been. applied toward completing the project; and
5. All permits and approvals required for the construction which is underway have been obtained.
( Signature of Grant Manager)
(Date)
DEP Agreement No. LP8949, Attachment B, Page 2 of 3
Engineer's Certification
of Disbursement Request
1, , being the Professional Engineer retained by
(name of Professional Engineer)
, am responsible for overseeing construction of the
(name of Grantee/Recipient)
project described in the Agreement and do hereby certify that:
I. Equipment, materials, labor, and services represented by the construction invoices have been satisfactorily purchased
or received and applied to the project in accordance with construction contract documents filed with and previously
approved by the Department of Environmental Protection;
2. Payment is in accordance with construction contract provisions;
3. Adequate construction supervision is being provided to assure compliance with construction requirements and
Florida Administrative Code Chapter62-600 or Chapter 62-604, as appropriate;
4. Construction up to the point of this disbursement is in compliance with the contract documents;
5. All changes, additions, or deletions to the construction contract(s) have been documented by change order and -all
change orders have been submitted to the Department; and
6. All additions or deletions to the Project which have altered the Project's performance standards, scope, or purpose
(since issue of the pertinent Department permit) have been identified in writing to the Department or are identified
and attached hereto.
Signature of Professional Engineer
Firm or Affiliation
DEP Agreement No. LP8949, Attachment B, Page 3 of 3
(Date) (P.E. Number)