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 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 %.

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 5126% 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 %.

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 5152% 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 %.

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 %.. Xxxxx Xxxxx/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 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 5126% 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 %.. Xxxx Xxxxxx/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 5111% 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 %.. Xxxxxxx Xxxxxxxx/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 %.. Xxx Xxxxxxxxx/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 5130% 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 %.. Xxxxxxx Xxx Xxxx/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 5110% 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/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 5192% 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 %.

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 5160% 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/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 513% 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 %.. Xxxx Xxxxxx/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 5126% 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 %.. Xxxxx Xxxx/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 Xxxxxxxx, 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 5110% 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 %.. Xxxxx Xxxxxxxx/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 5150% 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 %.. Xxxx Xxxxxx/Township Trustee / / 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 5138% 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 %.. Xxxxxxx Xxxxx/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 5152% 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 %.. Xxxx Xxxxxx/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 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 %.. 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 5173% 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 %.. Xxxx Xxxxxxxxx/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 5150% 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 %.. Xxxxx Xxxxxx/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 5180% 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 %.. Xxxxx Xxxxxxx/Design 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 5111% 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 %.. Xxxx Xxxxxx/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, PE/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 5111% 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 %.. Xxx Xxxxxxxxx/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 5142% 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 %.. Xxxxxxx Xxxxx/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 5131% 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 Xxxxxx/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 5152% 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 %.. Xxxxxxx Xxxxx/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 5110% 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 %.. Xxx Xxxxxx, 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 5125% 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/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 5189% 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 %.. Xxxxxxx Xxxxxxxxx/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 5156% 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 %.. Xxxxx Xxxxxxxxxxx/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 5180% 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 %.. Xxxxx X. Xxxxx/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 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 %.. Xxxxx Xxxxx/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 5155% 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 %.. Xxxx Xxxxx/Deputy 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 5174% 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 %.. Xxx Xxxxxxxxx/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 5131% 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 %.. Xxxxx Xxxxxxx/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 5141% 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 %.

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 5150% 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 %.. Xxxxx Xxxxxx/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 5150% 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 %.. Xxx Xxxxxxx/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 5171% 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 %.

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 5172% 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 %.. Xxx Xxxxxx/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 5156% 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 %.. Xxx Xxxxxx/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 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 %.. Dove Falll/Street 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 5110% 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 %.. Xxxxx Xxxxx/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 5131% 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/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 5110% 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 %.. Xxxxxxx Xxxxxx/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 5150% 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 %.. Xxxxx Xxxxxxx/Safety-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 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 %.. Xxxx Iwanacjek/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 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 %.. Xxxxx Xxxxx/Director of Public Service / / 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 5193% 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 %.. Xxxxx X. Xxxxxx/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 5148% 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 %.. Xxxxxxxxxxx Xxxxxxxx/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 5142% 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 %.

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 5150% 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 X. Xxxxx, Xx., 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 5180% 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 %.. Xxx Xxxxx/Project Coordinator / / 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 5146% 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 %.. Xxxxxxx Xxxxxxxx/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 5150% 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 %.. Xxxxxxx XxXxxxxx, P.E./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 5166% 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 %.. Xxx Xxxxxxxx/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 5115% 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 %.. Xxxxx Xxxx/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 5190% 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 %.

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 5127% 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 %.. Xxxxx Xxxxxx, 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 5153% 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/District 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 5111% 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 Xxxxxx/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 5138% 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 %.. Xxxxx Xxxxx/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 5112% 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 %.. Xxxxx Xxxxxxxx/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 5112% 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 %.

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 5110% 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 %.. Xxxxx Xxxxx/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 5165% 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 %.. Xxxx Xxxxx/Twp. Road Supt. / / 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 5150% 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 %.. Xxxxx Xxxxxx, 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 5110% 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 %.. Xxxx Xxxx, P.E./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 5126% 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 %.. Xxxx Xxxxxx/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 5149% 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 Born/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 510% 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 %. Xxxxx Xxxxxxx/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 5136% 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 %.. Xxxx Xxxxxxx/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 5148% 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 %.. Xxxxx Xxxx, 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 5130% 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 %.. Xxxxx Xxxxxx/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 %.. Xxx Xxxxxxxx/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 510% 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 %.. Xxxx Xxxxxxx/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 5110% 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 %.. Xxxx Xxxxxx/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 5150% 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 %.. Xxx Xxxxx/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 5131% 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 %.. Xxxxxxx Xxxxxxx/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 5136% 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 %.. Xxx Xxxxxxx/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 5126% 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 %.. 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 5140% 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 %.. Xxx Xxxxxx/Chief Deputy 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 5164% 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 %.. Xxxxx Xxxxx/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 5120% 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 %.. Xxxxx Xxxxxxxx/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 5110% 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 %.. Xxxxx Xxxx/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 %.. Xxxxx Xxxx III, 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 5136% 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 %.. Xxxx Xxxx/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 5152% 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 %.. Xxxxx Xxxxxxxxx/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 5131% 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 %.. Xxxx Xxxxx, PE/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 5154% 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 %.. Xxxx Xxxx/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 5141% 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 %.. Xxxxx Xxxxxxx, 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 5180% 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 %.. Xxxxx Xxx/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 5182% 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 %.. Xxxx Xxxxxxxxx/Public Works 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 5134% 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 %.

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 5130% 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 %.

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 5129% 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 %.. Xxxx Xxxxxx/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 5161% 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 %. Xxxxxxx Xxxxx, PE., SI/Project Engineer / / Date ( ) - Phone