Common use of YES NO Clause in Contracts

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 % of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx/Roadway Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 % of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx Xxxxx/Roadway Engineer Service Department Superintendent / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 26% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxx Xxxxxx/Roadway Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 51% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx/Roadway Engineer / / Date ( ) - Phone.

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 51% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx/Roadway Xxxx Xxxxxx, P.E./City Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 76% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxx Xxxxxxx/Roadway Engineer Administrative Deputy / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 % of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx Xxxxx/Roadway Engineer Public Works Dir. / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 50% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxxxx Xxxxxxxx/Roadway Engineer Project Manager / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 26% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxxxx Xxxxxxxx/Roadway Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 33% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx/Roadway Engineer / / Date ( ) - Phone.

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 26% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxx Xxxxxx/Roadway Engineer Service Dir. / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 10% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxxxx/Roadway Engineer Water/Sewer Superintendent / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 92% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx/Roadway Engineer / / Date ( ) - Phone.

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 48% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxxx Xxxx/Roadway Engineer , P.E./Project Manger / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 10% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx/Roadway Xxxxx Xxxxxxxxxxx, P.E./Consulting Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 41% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx/Roadway Engineer / / Date ( ) - Phone.

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 26% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx/Roadway Engineer Xxx Xxxxx, P.E./Project Manager / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 51% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxx Xxxxxxxx/Roadway City Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 25% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxxxxxxxxx Xxxx/Roadway Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 51% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxx Xxxxxxxxx/Roadway Engineer Village Administrator / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 30% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxxxxx Xxx Xxxx/Roadway Engineer Road Superintendent / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 71% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx/Roadway Engineer / / Date ( ) - Phone.

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 36% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx Xxxx/Roadway Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 26% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx/Roadway County Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 84% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxx Xxxxx/Roadway Engineer Director of Public Service / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your OPWC 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 33% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx Xxxxx/Roadway Engineer Village Administrator / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 60% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxxxx Xxxxxxxxxxx/Roadway Engineer Project Manager / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 0% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx Xxxxxxx/Roadway Engineer Pres., Board of Trustees / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 41% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx Xxxxxxxx/Roadway City Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 0% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxx Xxxxxxx/Roadway Engineer Administrator / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 50% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx Xxxxxx/Roadway Engineer Asst. Dir. of Public Services / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 46% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxxxx Xxxxxxxx/Roadway Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 % of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxXxxx/Roadway Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your OPWC 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 56% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx Xxxxxxxxxxx/Roadway Engineer Project Manager / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 65% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx/Roadway Engineer / / Date ( ) - Phone.

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 21% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx/Roadway Engineer Xxxxx Xxxxxxxxxxxx, P.E./Project Manager / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 31% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxx Xxxxx, PE/Roadway Project Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your OPWC 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 26% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx/Roadway Engineer Xxx Xxxxxx, P.E., P.S./Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 52% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxx Xxxxxx/Roadway Engineer Director of Public Works / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 25% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx/Roadway Engineer Project Manager / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 50% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx/Roadway Xxxx Xxxxxx, P.E./Sanitary Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxx Xxxxxx/Roadway Engineer Project Manager / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 10% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx Xxxxx/Roadway Engineer Village Administrator / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your OPWC 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 11% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxxx/Roadway Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 38% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx Xxxxx/Roadway Village Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 0% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxx Xxxxxxxxx/Roadway Engineer City Manager / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 50% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxx Xxxxxxxxx/Roadway City Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 50% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxxx Xxxx/Roadway Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 % of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxxxx Xxxxxxxx/Roadway Engineer Dir. of Development / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 25% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx/Roadway Engineer / / Date ( ) - Phone.

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 43% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx/Roadway Engineer / / Date ( ) - Phone.

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 10% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxx Xxxxx/Roadway Engineer Service Director / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 3% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxx Xxxxxx/Roadway Engineer Safety Service Director / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 26% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxxx Xxxx/Roadway Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 93% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx X. Xxxxxx/Roadway Chief Deputy Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 12% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx Xxxxxxxx/Roadway Engineer Project Manager / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your OPWC 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 73% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxx Beque/Roadway Engineer W.E. Xxxxxxxxx & Assoc. / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 78% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxx Xxxx/Roadway Engineer Service Director / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your OPWC 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 74% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxx Xxxxxxxxx/Roadway Engineer Village Administrator / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 % of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxx Xxxxxx/Roadway Deputy Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 30% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxxxx Xxxxx/Roadway County Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 26% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxxx/Roadway Engineer Project Manager / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 25% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxxxx Xxxxxx/Roadway Project Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your OPWC 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 36% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxx Xxxxxxx/Roadway Engineer Village Administrator / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 10% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx/Roadway Xxx Xxxxxxxxx, P.E., P.S./Project Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 10% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx Xxxxx/Roadway Engineer Water/Sewer Superintendant / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 31% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxxxxx/Roadway Chief Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 16% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxxxx Xxxxx/Roadway Engineer Project Manager / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 18% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx/Roadway Engineer / / Date ( ) - Phone.

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 30% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx/Roadway Engineer Manager / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 10% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxx Xxxxxx/Roadway Engineer Trustee / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 % of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx Xxxxx/Roadway Engineer Village Administrator / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 80% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx X. Xxxxx/Roadway City Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 46% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxx Xxxxx/Roadway Engineer Road Superintendent / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 49% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxBorn/Roadway Engineer Project Manager / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 50% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxx Xxxxxx/Roadway Engineer Township Trustee / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 87% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx Xxxx/Roadway Engineer Project Manager / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 42% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx/Roadway Engineer / / Date ( ) - Phone.

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 50% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx Xxxxxxx/Roadway Engineer Safety-Service Director / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 54% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx Xxxxxxxx/Roadway Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 43% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxxxx/Roadway Engineer Project Manager / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your OPWC 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 16% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx XxXxxxxxx/Roadway Engineer Project Manager / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your OPWC 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 28% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx Xxxxxxx/Roadway Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 50% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx/Roadway Xxxx Xxxxxx, P.E./City Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 30% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx XxxXxxxxxx/Roadway Engineer Project Manager / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 54% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx Xxxx/Roadway Engineer Project Manager / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 10% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx Xxxxxxxx/Roadway Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 10% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxx XxXXxxx/Roadway Engineer Water Superintendent / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 42% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxxxx Xxxxx/Roadway Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 48% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxxxxxxxx Xxxxxxxx/Roadway City Engineer / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 17% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx Xxxxxxxxx/Roadway Engineer Village Administrator / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your OPWC 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 73% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxx Xxxxx/Roadway Engineer Project Manager / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 73% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxx Xxxxxxxxx/Roadway Engineer Project Planning Director / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 70% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx Xxxxxx/Roadway Engineer Service Safety Director / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 83% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxxxx Xxxxxxxx/Roadway Engineer Administrator / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your OPWC 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 11% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx Xxxxxxxx/Roadway Engineer Village Administrator / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 26% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxx Xxxxxx/Roadway Engineer Project Manager / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 10% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxxxxx/Roadway Engineer Construction Section Manager / / Date ( ) - Phone

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 58% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx Xxxx/Roadway Engineer / / Date ( ) - Phone.

YES NO. If the answer is YES or if this disbursement uses the remainder of your 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 50% of the total project cost. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - AUTHORIZED CERTIFICATIONS All signatures must be original and in color ink. (Note: 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 %. Xxxxxx XxxxXxxxx Xxxxx/Roadway Engineer Safety Service Director / / Date ( ) - Phone