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INDIANA BROWNFIELDS PROGRAM - DISBURSEMENT REQUEST FORM <br />Instructions: This Disbursement Request Form is to be typed and completed by the Financial Assistance <br />Agreement Recipient for each payment request. <br />• The Disbursement Request Form is to be used for all eligible costs associated with the Financial <br />Assistance Agreement Recipient's brownfields redevelopment project. <br />• Attach a copy of the claim (a bill, invoice or a statement) supporting this Request. <br />• Requested amounts must be rounded to the nearest whole dollar. <br />• Attach the Program change order approval if any part of the current claim is a result of a change order. <br />Brownfield Program Site#: <br />Project Name: <br />Financial Assistance Recipient: <br />Contact Person: <br />Phone#: <br />Email: <br />Recipient's Authorized Representative: <br />Authorized Representative's Phone#: ( <br />9. Consultant: <br />10. Contact Person: <br />11. Phone#: <br />12. Email: <br />1.b. Funding Type; <br />13. Invoice#: <br />14. Description of work for which claim is being made (service, fees, type of, etc.) <br />15. <br />Amount of this Request: $ <br />16. <br />Original Financial Assistance Amount: $ <br />17. <br />Total Amount of Approved Change Orders: $ <br />18. <br />Revised Project Budget: $ <br />19. <br />Total Amount of Previous Disbursements: $ <br />20. <br />Balance Available after this Disbursement: $ <br />21. Is any part of this claim a result of a change order? YES NO <br />'If yes, please attach the Program change order approval <br />22. Do you want payment mailed directly to the consultant? YES NO <br />If yes, payment will be sent directly to the consultant listed in #9 above <br />23. Payment/Wiring Instructions (for the entity receiving payment) <br />23a. Bank Name: <br />23b. Bank Contact, Phone#: <br />23c. Account Number: <br />23d. Routing Number: <br />The undersigned hereby certifies that this Request is true and correct, that the claim underlying this Request <br />is due in accordance with the Recipient's Financial Assistance Agreement with the Authority, and that the <br />services contained in such claim were procured in accordance with Indiana's public bidding laws <br />and federal cross -cutting requirements (e.g., Davis -Bacon), if applicable. <br />AUTHORIZED REPRESENTATIVE SIGNATURE <br />Date <br />Revised August 2018 <br />