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EXHIBIT A <br />State of Indiana <br />STATE DRINKING WATER REVOLVING LOAN {SRF) PROGRAM <br />100 North Senate Avenue <br />P. O. Box 6015 <br />Indianapolis, Indiana 46206-6015 <br />(317) 232-8631 <br />REQUEST FOR A DISBURSEMENT <br />The undersigned Authorized Representative of the Qualified Entity named in this <br />Request, on behalf of such Qualified Entity, hereby (i) requests that the State make a <br />Disbursement, or cause a Disbursement to be made, in accordance with this Request and (ii) <br />directs that the State mail, or cause to be mailed, the Disbursement to the Qualified Entity or the <br />Contractor named in this Request. <br />Instructions <br />1. This Request is applicable only to costs of the Qualified Entity's drinking water <br />project eligible for financing from the State Drinking Water Revolving Loan Fund (the "SRF") <br />2. Combine multiple bills from a single contractor on one request form. <br />3. Attach a copy of the claim (a bill, an invoice or a statement) underlying this Request. <br />4. Complete the required information and please answer all questions. <br />S. Indicate on this Request if the Qualified Entity has paid all or part of the Contractor's <br />claim and is seeking reimbursement. Attach evidence that such payment was made and the date <br />on which it was made. <br />6. Inquires related to the status of a Disbursement request must be directed to the <br />Qualified Entity. The Qualified Entity can then contact this office for the information. Please <br />contact your contractors about this policy. <br />7. Requested amounts must be rounded to the nearest whole dollaz. <br />8. The Request must be typed. <br />430848 A-1 ~:c~c~ o ~ 199 <br />i M1 <br />.~..~ <br />C:t ~i~isP 4 ~..~ ~,~~4~$. <br />