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EXHIBIT C <br /> RLF-76 <br /> DISBURSEMENT REQUEST (R-09/02) <br /> Arkansas Natural Resources Commission <br /> Revolving Loan Fund <br /> Project Name: Request Number: <br /> Project Number: Loan No 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 /> b. Administration Costs(Land) <br /> C. Construction-Plant <br /> d. Construction-Line work <br /> e. Administration Costs(Const) <br /> f. A/E Basic Fees-Bid Phase <br /> g. AfE Basic Fees-Const. <br /> Phase <br /> h. Inspection Phase <br /> i. Start-Up Services <br /> Project Performance Fees _ <br /> O&M Manual <br /> I. Material Testing <br /> m. Project Performance <br /> Testing <br /> n. Equipment <br /> o. Allowance(Planning/Design) <br /> p. ADFA Fee <br /> q. Legal Fees <br /> r. Issuance Costs <br /> s. <br /> t. <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 By Typed or Printed Name and Title Telephone Number <br /> disbursement request <br /> accurately reflects the total RLF Signature of Engineering Consultant Date Signed <br /> amount due to dale and that all Prepared <br /> costs requested are in By Typed or Printed Name and Title Telephone Number <br /> accordance with the terms of <br /> the bond purchase agreement Signature of RLF official Date signed <br /> and RLF regulations. I further Approved <br /> certify that all work has been p By Typed or Printed Name and Title Telephone Number <br /> inspected and performed in <br /> Lrdance with RLF program Signature of Project Engineer Date signed <br /> irements. <br /> Typed of Printed Name and Title Telephone Number <br /> Page 1 of t <br />