Online Fund Payment Request Form
Berea
North End Sewer Rehabilitation Phase II
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
CO
Contingencies
$491,796.00
$0.00
$491,796.00
0.00
OW
OWDA Fee
$1,951.00
$1,951.00
$0.00
0.00
TS
Technical Services
$12,000.00
$0.00
$12,000.00
TS3
Construction Management
$53,600.00
$0.00
$53,600.00
Total:
$559,347.00
$1,951.00
$557,396.00
0.00