Laserfiche WebLink
CVLIIDIT 1'1 <br />REQUISITION FORM <br />Requisition No. <br />Business Name: <br />Business Address: <br />Pursuant to an executed Agreement between the City of San Leandro and the above named <br />entity, a request for a CDBG loan disbursement is being made. <br />The Participant requests a disbursement of funds in the amount of $ for payment of <br />reimbursement costs for the Project in accordance with the provisions of the Agreement. An itemization of <br />the improvements follows: <br />Description of Improvement Amount <br />1. $ <br />2. $ <br />3. $ <br />4. $ <br />5. $ <br />Total Costs $ <br />City Disbursement $ <br />The supporting documents (invoices, receipts, billing statements) attached to this requisition are <br />true and correct. <br />The disbursement of funds requested by this requisition is in conformity with the requirements of <br />the Agreement. <br />Authorized Officer of Date <br />Approved: Date: <br />Account: <br />*** For City Use Only *** <br />Fiscal Year 08-09 D-~ r <br />