SIB Disbursement Form B
(Address of Borrower)
Invoice #: ___________
Date: ______________
Draw #: ____________
SIB Loan #: _________
Job/Project: ______________________________
Voucher # Paid Date Warrant # Amount
Total of Invoice: $
This is to certify that the work as evidenced by an appropriate invoice of actual production, as attached to justify the above amounts, has been completed and in no way represents any degree of duplication of payments and that all costs were incurred in accordance with the terms and conditions of the Agreements listed on the vouchers attached.
________________________
Date: _______________
(Authorized Representative)
________________________________
Date: _______________
(Engineer)