CITY OF CLEVELAND DEPARTMENT OF COMMUNITY DEVELOPMENT DISBURSEMENT REQUEST FORM SECTION A: CONTRACTOR AND DISBURSEMENT REQUEST IDENTIFICATION Organization Program Contract No. Project No. HUD Matrix Code Payee Information SECTION B: DISBURSEMENT REQUEST Request No. Date Reporting Period Preparer Telephone No. Total to Date CD Contract Expenditures (See Budgetary Status Page) Less Retainage Total Expenditures Less Retainage (Line a minus Line b) Previous Disbursement Requests (through No. _____) Current Disbursement Request (Line c minus Line d) (a) (b) (c) (d) (e) Pursuant to the Agreement between the City of Cleveland, Ohio (the “City”) and (the “Organization”), dated , the undersigned, as a duly authorized representative of the above named organization, hereby requests on its behalf payment of the above amount which shall be applied to the cost of the Community Development Project (as defined in the Agreement). In connection with the foregoing request, the undersigned hereby certifies on behalf of the organization that: The organization has expended or incurred costs after execution of the Agreement in the aggregate amount identified on line “a” above on the Community Development Project. The organization hereby requests disbursement of the amount identified on line “e”. Date By Title SECTION C: CITY USE Date Received Initial Payment Final Progress Payment Payment APPROVALS Program Date Financial Date IDIS Data Date Compliance Exempt Date Accounting Date Compliance Manager Date Davis-Bacon/Affirm. Mktg./ADA Date Section 3/M-FBE/HOME Date Environmental/Historic Date Acquisition/Relocation Date LETTER OF CREDIT COMPLIANCE CERTIFICATION ORGANIZATION PROGRAM CONTRACT NO. REQUEST NO. DATE The undersigned hereby certifies that: (a) All prior draw requests under the Community Development Project have been fully disbursed within three (3) days of receipt by Organization for payment of project elements identified on prior Disbursement Requests as approved by the City; and (b) Evidence of cash disbursements, including lists of checks issued evidencing disbursement of the Community Development Project Funds within three (3) days of receipt for all prior draw requests, are attached hereto or have been forwarded to and accepted by the City; and (c) Community Development Project funds received by Organization pursuant to the draw request accompanying this certification shall be disbursed by Organization within three (3) days of receipt. IN WITNESS WHEREOF, I have hereunto set my hand this 20 . day of BY (Name) TITLE BUDGETARY STATUS ORGANIZATION PROGRAM CONTRACT NO. REQUEST NO. DATE LINE ITEM ACTIVITY A. Acquisition B. Architectural/Engineering C. Construction 1. Demolition 2. Site Improvements 3. Building Cons 4. Other BUDGET TOTAL PROJECT CURRENT TOTAL EXPEND. EXPEND. BALANCE BUDGET CD ALLOCATION CURRENT TOTAL EXPEND. EXPEND. BALANCE D. Other 1. 2. 3. TOTAL EXPENDITURES/COST DISTRIBUTION FUNDING SOURCE A. B. C. D. E. CD AMOUNT “Expenditure/Cost Distribution” represents a breakdown of the Total Current Expenditures TOTAL SCHEDULE OF DOCUMENTATION (REIMBURSEMENT) ORGANIZATION PROGRAM CONTRACT NO. REQUEST NO. DATE Adequate documentation of expenditures shall be provided by the organization to the City before any disbursement will be made. The documentation shall consist of invoices for the project (or an equivalent). The invoices shall show the date of payment and contain the following: The subcontractor’s or vendor’s name and address; the job name and location; a detailed description of work performed or material purchased (date, quantity, etc.); and a detailed itemization of costs incurred, including extensions. A copy of the cancelled check or cash receipt shall be attached to the appropriate invoice and be submitted with a schedule incorporating the following format: VENDOR/SUBCONTRACTOR INVOICE DATE INVOICE # TOTAL INVOICE AMOUNT CHECK # AMOUNT CHARGED TO CITY 1. 2. 3. 4. 5. 6. 7. Total Notes Attach the required invoices/documentation described above directly to this form, in the same order athe invoices/documentation are listed. Invoices must identify a specific cost for a specific period. Past due notices, summary statements, etc., are not acceptable documents for supporting costs. DOCUMENTATION OF DISBURSEMENTS FOR PREVIOUSLY REPORTED COSTS ORGANIZATION PROGRAM CONTRACT NO. REQUEST NO. DATE The listing below relates to cost items previously reported on Request No. *. VENDOR/SUBCONTRACTOR INVOICE DATE INVOICE # TOTAL INVOICE AMOUNT CHECK # AMOUNT CHARGED TO CITY COMMENTS 1. 2. 3. 4. 5. 6. 7. Total * This report should identify all the invoices disclosed on the referenced Request No. Notes Attach canceled checks directly to this form, in the same order as the invoices are listed. This form is not applicable to Request #1. If cancelled checks are being submitted from more than one previous “Request”, a separate report should be prepared for each of those previous “Requests”.