Common use of YES NO Clause in Contracts

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 61% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxx/Project Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6141% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxx/Project Xxxxx Xxxxxxx, P.E./City Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6152% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxx/Project Xxx Xxxxxx, P.E./City Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6181% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxx/Project Engineer Xxxxxx Xxxxxxx, P.E./Project Manager / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6181% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxx Xxxx/Project Engineer Chief, Division of Building and Zoning / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6177% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxX. Xxxxx/Project Engineer Director of Public Service / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6135% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxx Xxxx/Project Engineer Chief, Division of Building and Zoning / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6126% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxx/Project Engineer Water/Wastewater Director / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6150% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxx/Project Xxx Xxxxxxxx, P.E./City Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6187% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxx/Project Engineer Xxxxxxx Xxxxxxxx P.E./Project Manager / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6185% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxxxx Xxxxxx/Project Engineer Deputy Director, Public Works / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6131% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxx Xxxxx/Project Engineer Street Superintendent / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 61% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxxxx Xxxxxxxx/Project Cheif Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6179% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxx Xxxxx/Project Engineer City Engineer/Administrator / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6124% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxx Xxxxxxx/Project Engineer Asst. Superintendent / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6126% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxxx XxXxxxxxx/Project Engineer District Manager / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6146% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxx/Project Engineer Street Supt. / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 61% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxxxx Xxxxxxx/Project Engineer Township Trustee / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6192% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxxxxxxxx Xxxxxxxx/Project Village Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 61% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxxx Xxxxxxx, PE/Project Engineer Service Dir. / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6121% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxx/Project Engineer Kar Xxxxx X.X./Engineering Mamager / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6153% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxxx Xxxxxx/Project Engineer Engineering & Construction Manager / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6159% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxx/Project Engineer Xxxxxx Xxxxxxxx, P.E./Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6166% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxx Xxxxxxx-Xxxxx/Project Engineer Village Administrator / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6169% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxXxxxx/Project Engineer Water and Sewer Operator / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6159% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxxxxxx/Project Engineer Township Trustee / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 61% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxxxx Xxxxxxx/Project Engineer Director of Public Works / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6148% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxx Xxxxxxxx/Project Engineer Community Dev. Director / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6151% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxx/Project Xxxxxx, P.E./City Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6152% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxx/Project Xxxxx Xxxxx, P.E./City Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6146% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxxxx/Project Engineer Dir. of Engineering / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6178% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxx/Project Engineer Xxxxxxxxxxx Xxxxxx, P.E./Project Manager / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6178% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxx Xxxxxxxxx/Project Engineer Storm Water Coordinator / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6126% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxxxx Xxxxxxx/Project Engineer Athens Co Planner / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6182% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxx/Project Xxxxx Xxxxxx, P.E./City Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6175% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxx X. Xxxxxxxx/Project Xxxxxx County Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6152% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxx/Project Xxxxx Xxxxxx, P.E./City Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 61% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxx Xxxxxxx/Project Engineer Assistant Administrator of Operations / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 61% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxxxx Xxxxxxxx/Project Engineer Plant Operations Manager / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6150% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxxx Xxxxxxxxx/Project Engineer Admin./Finance Director / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6183% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxX. Xxxxx/Project Engineer Director of Public Service / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 61% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxx/Project Xxx Xxxxxxxx, P.E./City Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 61% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxxxx Xxxxxxxx/Project Engineer Director of Development and Public / / Date ( ) - Phone Service CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6150% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxxx PE, PS/Project Columbiana County Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6130% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxxxx Xxxxxxxxx, PE/Project Engineer Admin. Bureau Manager / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6121% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxx/Project Engineer Kar Xxxxx, X.X./Engineering Manager / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6163% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxx Xxxxxx, PE, PS/Project County Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6150% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxx X. Xxxxxxxx/Project Fulton County Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6166% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxx/Project Engineer Xxxxxxxxxxx Xxxxxx, P.E./Project Manager / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6129% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxxxx Xxxxxxxx/Project Engineer Vice Pres. / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6150% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxx/Project Xxxxx Xxxxxx, P.E./City Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6150% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxx X. Xxxxxxxx/Project Fulton County Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6130% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxx/Project Xxxxx Xxxxxx, P.E./Transportation Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6150% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxx/Project Xxxxxxx Xxxxxxx, P.E./Project Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6152% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxx/Project Xxxxxx, P.E./City Engineer / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6170% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxxxxx Xxxxxxx/Project Engineer Director of Engineering / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6140% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxx/Project Engineer Xxx Xxxxxxx, Jr./Village Administrator / / Date ( ) - Phone CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. VI.B. and VI. C. VI.C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that:

YES NO. If the answer is YES or if this disbursement uses the remainder of your OSGCIC OPWC assistance, your project file will be closed upon processing this request. As described in Appendix D of the Project Agreement, your minimum Percentage Contribution is 6117% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS Changes to project officials must be submitted in writing. PROJECT MANAGER CERTIFICATION: I hereby certify that the work items invoiced and included herein are exclusively associated with the Project, have been completed in a satisfactory manner, and are otherwise in accord with the terms and conditions of the Agreement. This request reflects project completion at an estimated %. Xxxx XxXxxxxxXxxxx Xxxxxx/Project Engineer Director of Planning and Program / / Date ( ) - Phone Management CHIEF EXECUTIVE OFFICER AND CHIEF FINANCIAL OFFICER CERTIFICATION: Pursuant to Section VI. B. and VI. C. of the Agreement, the undersigned Chief Executive Officer and Chief Fiscal Officer of the Recipient, as both are designated in Appendix B of the Agreement, hereby request the Administrator Director to disburse financial assistance moneys made available to Project in Appendix C of the Agreement (inclusive of any amendment thereto) to the payee as identified below in the amount so indicated which amount equals the product of the Disbursement Ratio and the dollar value of the attached cost documentation which was properly billed to the Recipient in exclusive connection with the performance of the Project. The undersigned further certify that: