MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALITY
DRINKING WATER AND MUNICIPAL ASSISTANCE DIVISION - REVOLVING LOAN SECTION
DRINKING WATER REVOLVING FUND (DWRF) AND CLEAN WATER STATE REVOLVING FUNDS (SRF/SWQIF)
REQUEST FOR DISBURSEMENT OF FUNDS
THIS INFORMATION IS REQUIRED UNDER AUTHORITY OF PARTS 52, 53, AND 54, 1994 PA 451.
PLEASE SEE OTHER SIDE FOR INSTRUCTIONS TO COMPLETE REQUEST
E. Recipient’s EIN
A. Project #
B. Request #
C. Period Covered by Request
D. Request Type
F. Loan Amount
 partial
 final
___________ to ___________
(M/D/Y)
(M/D/Y)
G. Recipient’s Name:
Phone #
Address:
H. Recipient’s Bank Name:
Phone #
Address:
Account Name:
ABA #
Account #
Special Instructions:
I. Budget Items (round amounts to the nearest dollar)
Approved Amount
Approved Amount
Incurred this Period
Incurred to Date
1. ASSET MANAGEMENT PROGRAM/FISCAL SUSTAINABILITY COSTS
2. PLANNING COSTS
3. RATE METHODOLOGY DEVELOPMENT COSTS
4. DESIGN ENGINEERING COSTS
5. LEGAL/FINANCIAL SERVICE FEES
6. ADMINISTRATIVE COSTS
7. BOND COUNSEL FEES
8. BOND ADVERTISEMENT COSTS
9. BID ADVERTISEMENT COSTS
10. CAPITALIZED INTEREST
11. LAND ACQUISITION/RELOCATION COSTS
12. LAND PURCHASE COSTS
13. CONSTRUCTION ENGINEERING COSTS
14. CONSTRUCTION COSTS (bid contracts)
15. CONSTRUCTION COSTS (force account)
16. EQUIPMENT COSTS
17. OTHER PROJECT COSTS
18. ADJUSTMENTS DUE TO OTHER FUNDING
19. TOTAL AMOUNT INCURRED THIS PERIOD
20. TOTAL CUMULATIVE AMOUNT INCURRED TO DATE
21. AMOUNT PREVIOUSLY DISBURSED
22. AMOUNT REQUESTED FOR DISBURSEMENT
I certify that I am an authorized representative of the recipient and am authorized to make the following certifications on behalf of the recipient: (i) there
is no pending litigation or event which will materially and adversely affect the project, the prospects for its completion, or the recipient’s ability to make
timely repayments on the obligation issued in connection with this project; (ii) the representations, warranties and covenants contained in the
supplemental agreement for the obligations pursuant to which this request for disbursement is submitted continue to be true and accurate in all material
respects as of the date hereof; (iii) to the best of my knowledge and belief, the costs above were incurred in accordance with the terms of the
supplemental agreement and the application for assistance for this project; and (iv) the amount requested for disbursement represents the loan amount
due, which has not previously been requested.
Authorized Representative Name (Print or Type): _________________________________________________ Title: ________________________
Authorized Representative Signature: ___________________________________________________________ Date: _______________________
PLEASE EMAIL THIS COMPLETED REQUEST TO YOUR DEQ PROJECT MANAGER
OR MAIL TO THE ADDRESS SHOWN ON THE REVERSE SIDE
(EQP 3522 REV. 2/18)
MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALITY
DRINKING WATER AND MUNICIPAL ASSISTANCE DIVISION - REVOLVING LOAN SECTION
DRINKING WATER REVOLVING FUND (DWRF) AND CLEAN WATER STATE REVOLVING FUNDS (SRF/SWQIF)
REQUEST FOR DISBURSEMENT OF FUNDS
THIS INFORMATION IS REQUIRED UNDER AUTHORITY OF PARTS 52, 53, AND 54, 1994 PA 451.
PLEASE SEE OTHER SIDE FOR INSTRUCTIONS TO COMPLETE REQUEST
E. Recipient’s EIN
A. Project #
B. Request #
C. Period Covered by Request
D. Request Type
F. Loan Amount
 partial
 final
___________ to ___________
(M/D/Y)
(M/D/Y)
G. Recipient’s Name:
Phone #
Address:
H. Recipient’s Bank Name:
Phone #
Address:
Account Name:
ABA #
Account #
Special Instructions:
I. Budget Items (round amounts to the nearest dollar)
Approved Amount
Approved Amount
Incurred this Period
Incurred to Date
1. ASSET MANAGEMENT PROGRAM/FISCAL SUSTAINABILITY COSTS
2. PLANNING COSTS
3. RATE METHODOLOGY DEVELOPMENT COSTS
4. DESIGN ENGINEERING COSTS
5. LEGAL/FINANCIAL SERVICE FEES
6. ADMINISTRATIVE COSTS
7. BOND COUNSEL FEES
8. BOND ADVERTISEMENT COSTS
9. BID ADVERTISEMENT COSTS
10. CAPITALIZED INTEREST
11. LAND ACQUISITION/RELOCATION COSTS
12. LAND PURCHASE COSTS
13. CONSTRUCTION ENGINEERING COSTS
14. CONSTRUCTION COSTS (bid contracts)
15. CONSTRUCTION COSTS (force account)
16. EQUIPMENT COSTS
17. OTHER PROJECT COSTS
18. ADJUSTMENTS DUE TO OTHER FUNDING
19. TOTAL AMOUNT INCURRED THIS PERIOD
20. TOTAL CUMULATIVE AMOUNT INCURRED TO DATE
21. AMOUNT PREVIOUSLY DISBURSED
22. AMOUNT REQUESTED FOR DISBURSEMENT
I certify that I am an authorized representative of the recipient and am authorized to make the following certifications on behalf of the recipient: (i) there
is no pending litigation or event which will materially and adversely affect the project, the prospects for its completion, or the recipient’s ability to make
timely repayments on the obligation issued in connection with this project; (ii) the representations, warranties and covenants contained in the
supplemental agreement for the obligations pursuant to which this request for disbursement is submitted continue to be true and accurate in all material
respects as of the date hereof; (iii) to the best of my knowledge and belief, the costs above were incurred in accordance with the terms of the
supplemental agreement and the application for assistance for this project; and (iv) the amount requested for disbursement represents the loan amount
due, which has not previously been requested.
Authorized Representative Name (Print or Type): _________________________________________________ Title: ________________________
Authorized Representative Signature: ___________________________________________________________ Date: _______________________
PLEASE EMAIL THIS COMPLETED REQUEST TO YOUR DEQ PROJECT MANAGER
OR MAIL TO THE ADDRESS SHOWN ON THE REVERSE SIDE
(EQP 3522 REV. 2/18)
DRINKING WATER AND CLEAN WATER STATE REVOLVING FUNDS
Instructions for Completing a Request for Disbursement of Funds
A.
Fill in the respective program project number that was assigned by the Michigan Department of Environmental Quality (DEQ).
B.
Identify the number of this disbursement request.
C.
Indicate the calendar period covered by this disbursement request.
D.
Check whether this is a partial or the final disbursement request.
Fill in the recipient’s federal employer identification number (EIN).
E.
F.
Fill in the loan amount as shown in the Order of Approval.
Fill in the loan recipient’s (bond issuer) name, address, and telephone number. This information must match data on file with
G.
the DEQ; if changes have occurred, please inform your DEQ project manager in a separate letter accompanying this request.
Fill in your bank’s name, address, telephone number, ABA identifying number, the account name and number, and any
H.
special instructions for the wire transfer to that account. This information must match data on file with the DEQ; if changes
have occurred, please inform your DEQ project manager in a separate letter accompanying this request.
I.
Recap approved eligible costs incurred to date for each budget item. Show the amount requested for the period covered by
this request, and then the cumulative amount to date from project inception. Entries in this section must be rounded to
the nearest dollar. If costs have been incurred for a budget item that was not shown in the DEQ Order of Approval, please
inform your project manager in a separate letter accompanying this request.
Enter the costs invoiced and/or paid for services directly associated with municipality’s Asset Management Program.
1.
Include salaries of municipal employees, if applicable.
2.
Enter the costs invoiced and/or paid for planning (do not include costs of tangible assets such as pilot facilities and
test wells).
3.
Enter the costs invoiced and/or paid for services directly associated with the development and enactment of the
municipality’s rate methodology and any related ordinances.
4.
Enter the costs invoiced and/or paid for project design work required prior to actual construction.
5.
Enter the costs invoiced and/or paid for legal or financial services except costs associated with the issuance of
bonds related to this project.
6.
Enter the costs incurred for salaries and indirect costs of the water supplier or municipal employees involved in the
project administration.
7.
Enter the costs invoiced and/or paid for legal or financial services associated with the issuance of bonds related to
this project.
8.
Enter the costs invoiced and/or paid to publish legal notices related to the sale of bonds related to this project.
9.
Enter the costs invoiced and/or paid to publish advertisements for bids for the project construction contracts.
10.
Enter only the amount of capitalized interest invoiced and/or paid for the period covered by this request.
11.
Enter the costs invoiced and/or paid for services related to compliance with the federal Uniform Relocation
Assistance and Real Property Acquisition Policies Act (49 CFR Part 24).
12.
Enter the costs invoiced and/or paid for the purchase of property which was deemed eligible and included in the
Supplemental Agreement.
13.
Enter the costs invoiced and/or paid for project construction engineering services.
14.
Enter the costs invoiced and/or paid under the project construction contracts.
15.
Enter the costs incurred for salaries and indirect costs of the water supplier or municipal employees involved in the
project construction labor ($50,000 limit).
16.
Enter the costs invoiced and/or paid for equipment purchased as part of this project.
17.
Enter other costs invoiced and/or paid for miscellaneous items that were approved by the DEQ for inclusion in this
project. If new items have been procured, please inform your project manager in a separate letter accompanying
this request.
18.
Enter adjustment which arises from reimbursements by other funding sources or the use of cash on hand.
19.
Enter the sum of the amounts shown in Column 1 (Amount Incurred this Period).
20.
Enter the sum of the amounts shown in Column 2 (Amount Incurred Cumulative to Date).
21.
Enter the total amount of funds previously paid (Line 20 on the previous disbursement request).
22.
Subtract Line 21 from line 20 to arrive at the Amount Requested for Disbursement.
NOTE: EXCEPT FOR REQUESTS #1 AND #2, YOU MAY SUBMIT NO MORE THAN ONE REQUEST FOR DISBURSEMENT
DURING A CALENDAR MONTH.
Provide this Request for Disbursement of Funds and the required incurred cost documentation to your DEQ
Project Manager via email or mail to:
REVOLVING LOAN SECTION
DRINKING WATER AND MUNICIPAL ASSISTANCE DIVISION
MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALITY
PO BOX 30817
LANSING MI 48909-8311
Telephone: 517-284-5433
(EQP 3522 REV 2/18)
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