Online Fund Payment Request Form
Bloomingburg
Miron St. Force Main 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
Precise Boring of Ohio, LLC
$52,428.16
$26,116.53
$26,311.63
CO
Contingencies
$0.00
$0.00
$0.00
0.00
OW
OWDA Fee
$400.00
$400.00
$0.00
0.00
TS
Technical Services
$38,500.40
$30,037.99
$8,462.41
Total:
$91,328.56
$56,554.52
$34,774.04
0.00