request_for_payment__expenditure_verification

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					                   DEPARTMENT OF ECONOMIC AND COMMUNITY DEVELOPMENT
                      REQUEST FOR PAYMENT/EXPENDITURE VERIFICATION
                                  SPONSOR INFORMATION



Name:                                                                      Payment #:
Street Address:                                                            Budget Period:
Municipality:                                                              Contract #:
Zip Code:                                                                  HDS/Proj. #
                                                                           % Expended

DECD Project Funds:
Total Other Funds:
Total Budget:
Project Name:
Sponsor FEIN:
TEPF# :




                         I. PAYMENT REQUEST & EXPENDITURE VERIFICATION
                                                     Instructions:

 1. This Payment Request represents the DECD funds necessary to meet eligible project expenditures that have already
 been incurred or paid.


 2. I understand that the DECD approval of this Request for Payment and Expenditure Verification in no way relieves me of
 my obligation’s under my Assistance Agreement with the DECD, and that payments made, are for eligible costs within
 current approved budget line item amounts. I understand that the DECD reserves the right to determine eligible costs
 based on the final audit of project funds. Furthermore, all costs determined by the DECD, at its sole discretion, to be
 ineligible but paid for with DECD funds, shall immediately be repaid.


 3. I understand that the Schedule of Expenditures, with attached copies of general contractor's periodical estimate, should
 be submitted (only if DECD is funding the general contract). Upon receipt of the DECD funds, the Sponsor must expend
 these funds within 30 days. The Sponsor must provide verification of expenditures by returning the "reconciled" Schedule
 of Expenditures (see Sample Format B) with check numbers identified, to the Project Manager within 30 days of receiving
 the payment or with the next payment request, whichever is sooner.


      4. I hereby request payment of DECD funds only for the above referenced project in the amount of
         $                        as itemized on the following pages.




                                                                                                                  Page 1

     Revised Feb. 27, 2004
     Effective March 1, 2004
                      Request for Payment/Expenditure Verification


                                          DECD Current          Total
                                             Approved        Previously   Balance      This       New
Account             Line Item                 Budget           Drawn      Available   Request    Balance
                                       Acquisition and Site Development
   1410   Land Cost                                                       $     -               $        -
   1411   Building Cost                                                   $     -               $        -
   1412   Surveys & Maps                                                  $     -               $        -
   1413   Title Exam/Insur.                                               $     -               $        -
   1414   Recording Fees                                                  $     -               $        -
   1415   Closing Costs                                                   $     -               $        -
   1416   Legal Costs/Acq.                                                $     -               $        -
   1417   Site Improvements                                               $     -               $        -
   1418   Unusual Site Imp.                                               $     -               $        -
   1419   Utility Hookups                                                 $     -               $        -
   1420   Demolition                                                      $     -               $        -
   1421   Envir. Remediation.                                             $     -               $        -
   1422   Site Bond Premium                                               $     -               $        -
   1423   Acq. Prop. Oper. Exp.                                           $     -               $        -
   1424   Gross Site Income                                               $     -               $        -
                                                                          $     -               $        -
          Total Acq. & Site Dev.          $            -  $          -    $     -     $    -    $        -
                                        Architectural and Engineering
   1430   Design Consultant                                               $     -               $        -
   1431   Design Consult. – Admin.                                        $     -               $        -
   1432   Design Consult. – Eng.                                          $     -               $        -
   1433   Supplemental Serv.                                              $     -               $        -
   1434   Blueprints & Supplies                                           $     -               $        -
   1435   Borings & Test Pits                                             $     -               $        -
   1436   Environmental Studies                                           $     -               $        -
   1437   Life Cycle Cost Analysis                                        $     -               $        -
   1438   Clerk of the Works                                              $     -               $        -
   1439   Concrete Testing                                                $     -               $        -
                                                                          $     -               $        -
          Total Arch. & Eng.               $          -  $           -    $     -     $    -    $        -
                                               General Contract
   1440   Site Improvements (in GC)                                       $     -               $        -
   1441   Main Buildings – New                                            $     -               $        -
   1442   Main Buildings – Rehab.                                         $     -               $        -
   1443   Other Buildings                                                 $     -               $        -
   1444   Demolition (if part of GC)                                      $     -               $        -
   1445   General Requirements                                            $     -               $        -
   1446   Builder’s Overhead                                              $     -               $        -
   1447   Builder’s Profit                                                $     -               $        -
   1448   Bond Premium                                                    $     -               $        -
   1449   Building Permits                                                $     -               $        -
   1550   Other Permits                                                   $     -               $        -
   1551   Hard Cost Contingency                                           $     -               $        -
                                                                          $     -               $        -
          Total General Contract           $          -   $          -    $     -     $    -    $        -

Continued on next page.
                                                                                                Page 2




 Revised Feb. 27, 2004Request      for Payment/Expenditure Verification
 Effective March 1, 2004
                                          DECD Current       Total
                                            Approved      Previously      Balance      This       New
Account              Line Item               Budget         Drawn         Available   Request    Balance
                                         Furnishings and Equipment
   1460 Office/Maintenance Equip.                                         $     -               $        -
   1461 Furniture & Appliances                                            $     -               $        -
                                                                          $     -               $        -
          Total Furnishings & Equip.      $          -    $          -    $     -     $    -    $        -
                                         Financing and Interim Costs
   1470   DECD Interest                                                   $     -               $        -
   1471   Property Taxes                                                  $     -               $        -
   1472   Property Insurance                                              $     -               $        -
   1473   Const. Loan Commit. Fee                                         $     -               $        -
   1474   Permanent Loan Orig. Fee                                        $     -               $        -
   1475   CHFA Tax Credit Fee                                             $     -               $        -
   1476   Other Fin. Fees and Interest                                    $     -               $        -
                                                                          $     -               $        -
          Total Financing & Interim       $          -  $         -       $     -     $    -    $        -
                                          Other Development Costs
   1480   Sponsor/Devel. Legal                                            $     -               $        -
   1481   DECD Legal                                                      $     -               $        -
   1482   Accounting                                                      $     -               $        -
   1483   Audit                                                           $     -               $        -
   1484   Cost Certification                                              $     -               $        -
   1485   Appraisals                                                      $     -               $        -
   1486   Market Analysis                                                 $     -               $        -
   1487   Res. Training/Buy. Ed.                                          $     -               $        -
   1488   Lease Up & Marketing                                            $     -               $        -
   1489   Relocation                                                      $     -               $        -
   1490   Contractual Services                                            $     -               $        -
   1491   Developer’s Fee                                                 $     -               $        -
   1492   Operating Deficit Reserv.                                       $     -               $        -
   1493   Other Req. Cap. Reserves                                        $     -               $        -
                                                                          $     -               $        -
          Total Other Dev. Costs          $             -   $         -   $     -     $    -    $        -
                                              Soft Cost Contingency
   1500 Soft Cost Contingency                                             $     -               $        -
                                                                          $     -               $        -
          Total Soft Cost Contingency     $            -   $          -   $     -     $    -    $        -

          Total Project Costs             $            -   $          -   $     -     $    -    $        -




                                                                                                Page 3




 Revised Feb. 27, 2004
 Effective March 1, 2004
                                                    II. CERTIFICATIONS


1. I hereby certify that all funds to be received from the State of Connecticut in connection with the project shall be managed
pursuant to the Project Expenditures Account Agreement.

2. I hereby certify that the Project Expenditures Account balance for this project, as of ____________________(date)
per project records, taking into account all items of expenditure is    $                      .(DECD funds) This amount
is on deposit with______________________ in the city of ________________________.

3. I certify that this Request for Payment/Expenditure Verification is in accordance with the provisions of Section 8-206(d)
of the Connecticut General Statutes and Subtitle A of Title II of the National Affordable Housing Act of 1990, as amended,
and applicable program regulations, and that these funds will be used for project costs approved by the Commissioner
of DECD under the Agreement Concerning Loan Advances and/or Assistance Agreement dated________________.

4. I hereby certify that, in addition to this DECD Request for Payment, I shall make payments from the other project
funding sources in the amount of $                           (non DECD funds). Payments from the other funding sources
should be for the same applicable line items as included in this payment request in accordance with the approved budget.

5. I herby certify that the cumulative amount (all funds) actually expended to date prior to this request is $____________
(Expended means that payments have been made to vendors for eligible and budgeted project expenses.)

 6. I hereby certify that I am responsible for ensuring that all contracts and obligations are paid in full and that all applicable
releases, payment documentation (i.e. receipts and invoices) and all required insurance coverages are obtained and on file, at
Sponsor's place of business.

7. I hereby certify that I am in conformance with all contractual obligations of the Assistance Agreement, including Articles (4)
Procedural Conditions to State's Obligation to Make Disbursement, (5) Representations and Warranties of the Developer, (6)
Covenants and Agreements of the Developer.

8. I hereby certify that the requested Disbursement will be used solely to pay or reimburse Eligible Costs actually incurred or
paid by the Developer in accordance with the Agreement, and have not been the basis of any previous Disbursement.


9. I hereby certify that I am duly authorized to execute this request.




           Signature (Authorized)                                                   Date




           Print or Type Name and Title of Signatory




                                                                                                                        Page 4


      Revised Feb. 27, 2004
      Effective March 1, 2004
                                         III. STAFF RECOMMENDATION

I have reviewed and I approve this Payment Request/Expenditure Verification. The budget period is current and
eligible costs do not exceed approved budget line item amounts. The most recent Quarterly Development Compliance
Report dated                             and all required attachments have been submitted, reviewed and indicate
that progress is satisfactory unless noted in an attachment.




               Project Manager                                                   Date




               Director                                                          Date




               Division Director                                                 Date




     Revised Feb. 27, 2004
     Effective March 1, 2004
                                           Schedule of Expenditures
Sponsor:                                                       Proj. Name:
Contract Number:                                               Payment #:
Budget Period:                                                 Date:

 Incurred Costs - (If you are only providing an invoice number for an incurred cost, resubmit this form
  within 30 days or with the next payment request, whichever is sooner, and include the check number
                                       for that invoice identified.)*
 Date of                                                                                                     Bud. Line
 Invoice              Payee               Invoice No.* Check No. Amount       Budget Line Item               Item #




  Paid Costs - (A check number must be provided below.)
 Date of                                                                                                     Bud. Line
 Check                Payee               Invoice No.* Check No. Amount       Budget Line Item               Item #




                               TOTAL                            $         -


                                                                                            Amount of This
            Summary By Budget Line Item (This payment only.)         Budget Line No.          Request




                                  TOTAL                                                     $          -

                           Completed by: Signature
                                                                                                               Page 6
                                   Printed Name
                                             Title




    Revised Feb. 27, 2004
    Effective Marach 1, 2004
                                       Schedule of Expenditures - SAMPLE Format A

Sponsor:                  Hudson View Nonprofit Agency                    Proj. Name:
Contract Number:          2002-064-057-000-010                            Payment #:    2
Budget Period:            Jan. 1, 2001 - Dec. 31, 2003                    Date:         6/1/2002


Incurred Costs - (If you are only providing an invoice number for an incurred cost, resubmit this form within
   30 days or with the next payment request, whichever is sooner, and include the check number for that
                                             invoice identified.)*
  Date of                                                                                                                  Bud. Line
  Invoice                     Payee             Invoice No. * Check No.   Amount        Budget Line Item                   Item #
  1/25/2002    J. P. Construction                       2101              $ 4,500.00    General Requirements                   1445
    3/7/2002   Management Company                       2159              $    364.72   Office Maintenance/Equip.              1460
  3/21/2002    B.A. Muzio & Co.                         2221              $    560.06   Property Insurance                     1472
  4/18/2002    Nationwide Insurance                     2225              $    279.98   Property Insurance                     1472
  5/30/2002    ACE Inc.                                 2314              $    772.23   Clerk of the Works                     1438
  5/30/2002    Engineering Unlimited                    2345              $    250.00   Market Analysis                        1486
  7/11/2002    MDC Water                                2418              $    363.40   Furniture and Appliances               1461
  8/22/2002    Architects Limited                       2464              $    272.15   Clerk of the Works                     1438
  9/19/2002    Materials Testing                        2556              $    131.43   Borings & Test Pits                    1435
 10/17/2002    John Smith                               2635              $    240.99   Market Analysis                        1486
 11/25/2002    MKC Inc.                                 2678              $    480.25   Furniture and Appliances               1461



  Paid Costs - (A check number must be provided below.)
  Date of                                                                                                                  Bud. Line
  Check                   Payee                 Invoice No. * Check No. Amount      Budget Line Item                       Item #
  6/27/1995 J. P. Construction                          3642       6906 $ 4,335.48 General Requirements                        1445
  7/11/1995 FDR Attorney's                              3798       6929 $    260.00 Legal Costs/Acq.                           1416




                                  TOTAL                                   $ 12,810.69


                                                                                                       Amount of This
                  Summary By Budget Line Item (This payment only.)             Budget Line No.           Request
               General Requirements                                                 1445               $     8,835.48
               Office Maintenance/Equip.                                            1460               $       364.72
               Furniture and Appliances                                             1461               $       843.65
               Market Analysis                                                      1486               $       490.99
               Property Insurance                                                   1472               $       840.04
               Clerk of the Works                                                   1438               $     1,044.38
               Borings & Test Pits                                                  1435               $       131.43
               Legal Costs/Acq.                                                     1416               $       260.00

                                        TOTAL                                                          $       12,810.69



                                 Completed by: Signature
                                        Printed Name                                                                       Page 7
                                                  Title




       Revised Feb. 27, 2004
       Effective March 1, 2004
                  VERIFICATION of HOME Schedule of Expenditures - SAMPLE Format B
HOME Sponsor:          Hudson View Nonprofit Agency                      Proj. Name:
Contract Number:       2002-064-057-000-010                              Payment #:      2
Budget Period:         Jan. 1, 2001 - Dec. 31, 2003                      Date:           6/15/2002

  Incurred Costs - (If you are only providing an invoice number for an incurred cost, resubmit this form
 within 30 days or with the next payment request, whichever is sooner, and include the check number for
                                          that invoice identified.)*
 Date of                                                                                                                 Bud. Line
 Invoice                   Payee               Invoice No. * Check No.   Amount          Budget Line Item                Item #
 1/25/2002   J. P. Construction                        2101       6668   $   4,500.00    General Requirements                1445
  3/7/2002   Management Company                        2159       6745   $      364.72   Office Maintenance/Equip.           1460
 3/21/2002   B.A. Muzio & Co.                          2221       6747   $      560.06   Property Insurance                  1472
 4/18/2002   Nationwide Insurance                      2225       6770   $      279.98   Property Insurance                  1472
 5/30/2002   ACE Inc.                                  2314       6869   $      772.23   Clerk of the Works                  1438
 5/30/2002   Engineering Unlimited                     2345       6871   $      250.00   Market Analysis                     1486
 7/11/2002   MDC Water                                 2418       6930   $      363.40   Furniture and Appliances            1461
 8/22/2002   Architects Limited                        2464       6957   $      272.15   Clerk of the Works                  1438
 9/19/2002   Materials Testing                         2556       7029   $      131.43   Borings & Test Pits                 1435
10/17/2002   John Smith                                2635       7085   $      240.99   Market Analysis                     1486
11/25/2002   MKC Inc.                                  2678       7144   $      480.25   Furniture and Appliances            1461



  Paid Costs - (A check number must be provided below.)
 Date of                                                                                                                 Bud. Line
  Check                  Payee                 Invoice No. * Check No. Amount        Budget Line Item                    Item #
 6/27/1995 J. P. Construction                          3642       6906 $   4,335.48 General Requirements                     1445
 7/11/1995 FDR Attorney's                              3798       6929 $      260.00 Legal Costs/Acq.                        1416



                                 TOTAL                                   $   12,810.69


                                                                                                        Amount of This
               Summary By Budget Line Item (This payment only.)                Budget Line No.            Request
             General Requirements                                                   1445                $    8,835.48
             Office Maintenance/Equip.                                              1460                $      364.72
             Furniture and Appliances                                               1461                $      843.65
             Market Analysis                                                        1486                $      490.99
             Property Insurance                                                     1472                $      840.04
             Clerk of the Works                                                     1438                $    1,044.38
             Borings & Test Pits                                                    1435                $      131.43
             Legal Costs/Acq.                                                       1416                $      260.00

                                       TOTAL                                                            $    12,810.69



                               Completed by: Signature
                                      Printed Name                                                                       Page 8
                                                Title




             Revised Feb. 27, 2004
             Effective March 1, 2004

				
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