FLORIDA INLAND NAVIGATION DISTRICT

ASSISTANCE PROGRAM

PAYMENT REIMBURSEMENT REQUEST FORM

PROJECT NAME: _________________________________ PROJECT NO.:_________

PROJECT SPONSOR: _________________________________ BILLING NO.:___________

Amount of Assistance _______________________

All Funds Previously Requested (-) _______________________

Balance Available = _______________________

Funds Requested _______________________

Less Retainage (-10% unless final) (-) _______________________

Check Amount = _______________________

Balance Available _______________________

Less Check Amount (-) _______________________

Balance Remaining = _______________________

SCHEDULE OF EXPENDITURES

Expense Description Check No. Total Applicant FIND

(Should correspond to Vendor Name and Date Cost Cost Cost

Cost Estimate Sheet

Categories in Exhibit "B") ______________________________________________________________________________

FIND - Form No. 90-14 (NOTE: Signature Required on Page 2)

Effective Date __-__-02)

===============================================================================================================Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing.” This notice is required by Sec. 668.6076, F.S., which is effective July 1, 2006.