SIB Disbursement Form A

(Address of Borrower)

                                                                                                                         Invoice #_____________
                                                                                                                         Date:________________
                                                                                                                                      

                                                                                                                        Project: ______________
                                                                                                                         Draw #: ______________
                                                                                                                         SIB Loan #:___________

TO:        Ohio Department of Transportation
               Office of Economic Development
               1980 West Broad Street, 2nd Floor
               Columbus, Ohio  43223

Certification Statement:
I certify that I have checked and verified the attached detail for partial payment; that to the best of my knowledge and belief it is a true and correct statement of work performed and/or material supplied by the Contractor; that all work and/or materials included in this partial payment has been inspected by me and/or my duly authorized representative or assistants and that it has been performed and/or supplied in full accordance with requirements of the referenced contract; and that partial payment claimed and requested is correctly computed on the basis of work performed and/or material supplied to date.

Also, that each item for which payment is requested is a payable cost of the loan proceeds in accordance with the terms and conditions of this loan agreement and none of the items for which the payment is proposed to be made has formed the basis for any payment theretofore made from the loan proceeds; that each item for which payment is proposed to be made is or was necessary in connection with the Project, and each payee has submitted appropriate waivers of any mechanics' or other liens and affidavit as required.

_____________________________________________                     Date ______________________
City/County/Village/Project Engineer

_____________________________________________                     Date ____________________
City Manager/Mayor/Commissioner

ODOT APPROVED: ___________________                Date ____________________

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