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DISBURSEMENT REQUEST FORM <br />(Greenway Terrace Project) <br />Number <br />Date: <br />, 2017 <br />The undersigned, pursuant to that certain LHIA Loan Agreement dated as of <br />, 2017 (the "Loan Agreement"), by and between the City of Ramsey (the <br />"City") and Ramsey Station Apartments Limited Partnership (the "Borrower"), hereby certifies and <br />requests as follows: <br />1. The Borrower requests that the following amounts be paid to Borrower by Title for <br />payment or reimbursement to the entities below for eligible costs under the Loan <br />Agreement: <br />Name and Address of Payee Amount Requested to be Paid <br />a. $ <br />b. $ <br />c. $ <br />d. $ <br />2. Attached hereto are invoices with respect to each item for which payment is requested <br />pursuant to paragraph 1. <br />3. The Borrower certifies that the disbursements are for Project Costs as defined in the Loan <br />Agreement. <br />US.113578590.01 <br />C-2 <br />