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Payments requested are as follows: <br />a. X amount to Person or Account Y for Z goods or services. <br />b. Payment / Wire Instructions <br />Attached hereto are invoices, cancelled checks, detailed receipts, purchase orders, change orders, <br />and similar instruments which support and validate the above requested payments. Also attached <br />hereto are "bills paid" affidavits and supporting documentation in the standard fom-i for City <br />M= <br />Pursuant to the Reimbursement Agreement, after receiving this payment request, the City has <br />inspected the PID Pro ect(s) (or completed segment) and confirmed that said work has been <br />3 <br />completed in accordance with approved plans and all applicable governmental laws, -rules, and <br />regulations. <br />I hereby declare that the above representat 'ions and warranties are true and correct. <br />Fremainder of page left blank intentionally] <br />L <br />01 5 8 1.0100001 \4908-9229-31 5.v5 <br />