Online Fund Payment Request Form
Adams County Regional Water District
US 52 Waterline Replacement
Disbursement Request:
(#'s only)
Payee:
Invoice Number:
Invoice Date:
(mm/dd/yyyy)
Total Invoice Amount:
(#'s Only, 0.00)
Invoice Amount to be paid by OWDA:
(#'s Only, 0.00)
Disbursement Request Detail
Contractor Name
Encumbered
Disbursed
Balance
Requested
Amount
A
Unger Construction, Ltd.
$199,220.00
$176,816.38
$22,403.62
CO
Contingencies
$33,322.00
$0.00
$33,322.00
0.00
OW
OWDA Fee
$0.00
$0.00
$0.00
0.00
TS
Technical Services
$8,400.00
$8,222.47
$177.53
TS1
Administration
$1,058.00
$944.66
$113.34
TS4
Design
$8,000.00
$8,000.00
$0.00
0.00
Total:
$250,000.00
$193,983.51
$56,016.49
0.00