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EXHIBIT C RLF-76 <br /> DISBURSEMENT REQUEST (R-12i09) <br /> Arkansas Natural Resources Commission <br /> Revolving Loan Fund <br /> Project Name: Request Number: <br /> F. ,.ct Number: Loan Number: Percent Complete: <br /> Employer Identification No.: <br /> Cost Classification Costs Incurred RLF Eligible Previous RLF RLF Payment Due <br /> to Date Amount Disbursements this Request <br /> a. Land Acquisition <br /> Administration <br /> b. Costs(Land) <br /> Construction- <br /> c. Tank <br /> Construction- <br /> d. Pump Station(s) <br /> Construction- <br /> e. Rehabilitation Work <br /> A/E Basic Fees <br /> f. Bid Phase ('see below) <br /> A/E Basic Fees <br /> g. Const.Phase <br /> h. Inspection Phase <br /> i. Start-Up Services <br /> Project Performance <br /> j. Fees <br /> k. 08M Manual <br /> I. Material Testing <br /> Project Performance <br /> m. Testing <br /> n. Equipment <br /> Allowance <br /> o. (Planning/Design) <br /> p. ADFA Fee <br /> q. Legal Fees <br /> r. Issuance Costs <br /> S. <br /> `reimbursement to City <br /> TOTAL <br /> Signature of Authorized Certifying Official Date Report Submitted <br /> I certify that to the best of my Requested& <br /> knowledge,that this Approved Typed or Printed Name and Title Telephone Number <br /> disbursement request accurately Bv <br /> reflects the total RLF amount due Signature of Engineering Consultant Date Signed <br /> to date and that all costs Prepared& <br /> requested are in accordance with Approved Typed or Printed Name and Title Telephone Number <br /> the terms of the bond purchase By <br /> agreement and RLF regulations. Signature of RLF Official Date Signed <br /> I further certify that all work has Approved for <br /> been inspected and performed in Payment Typed or Printed Name and Title Telephone Number <br /> acri-irdance with RLF program gv <br /> r iments. Signature of Project Engineer Date Signed <br /> Typed of Printed Name and Title Telephone Number <br /> Page 1 of 1 <br />