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DISBURSEMENT REQUEST INFORMATION <br />Community: <br />Mailing Address: <br />Project No.: CS <br />Request No.:_ <br />Contact Person: Contact Phone No.: ( ) <br />Community's Authorized Representative: <br />Authorized Representative's Phone No.: <br />Description of Work for which claim is being made (service, fees, type of, etc.): <br />Contractor <br />Address <br />Original Loan Amount ................................................................... <br />Total Amount of Previous Disbursements ............................................ <br />Amount of this Request ................................................................. <br />Balance Available after this Disbursement .......................................... <br />Amount Requested <br />Is a portion of the claim underlying this Request subject to retainage under I.C. 36-1-12- <br />14 or a similar law? YES NO <br />If yes the retainage amount is .......................................................... $ <br />Has the Qualified Entity paid the request and seeking reimbursement? YES _ NO <br />The undersigned hereby certifies that this Request is true and correct, that the claim underlying <br />this Request is legally due (and is payable from the SRF) in accordance with the Financial <br />Assistance Agreement with the State. <br />DATE: <br />SIGNATORY SIGNATURE <br />430848 A-2 <br />