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Form Of Requisition

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APPENDIX C

FORM OF REQUISITION

NVTA Project Number: __________________

NVTA Project Title: __________________________________________________

Draw Request Number: __________________

Date: ______________ __, 20___

Northern Virginia Transportation Authority

3040 Williams Drive

Suite 200

Fairfax, Virginia 22031

Attention __________________________, Program Coordinator:

This requisition, including required Detailed PayGo and/or Detailed NVTA Bond Proceeds

Request Forms, is submitted in connection with the Standard Project Agreement for Funding and

Administration dated ________________ ___, 20___ (the "Agreement") between the Northern Virginia

Transportation Authority ("NVTA") and _____________________________________________

(the "Recipient Entity"). The Recipient Entity hereby requests $__________________ of NVTA funds,

to pay the costs of the Project set forth in the Attached Detailed PayGo and/or Detailed NVTA Bond

Proceeds Request forms and in accordance with the Agreement. Also included are copies of each

invoice relating to the items for which this requisition is requested.

The undersigned certifies (i) the amounts included within this requisition will be applied solely

and exclusively for the payment or the reimbursement of the Recipient Entity’s approved costs of the

Project, (ii) the Recipient Entity is responsible for payment to vendors/contractors, (iii) the Recipient

Entity is not in default with respect to any of its obligations under the Agreement, including without

limitation (but only if applicable) the tax covenants set forth in Appendix D to the agreement, (iv) the

representations and warranties made by the Recipient Entity in the Agreement are true and correct as of

the date of this Requisition and (v) to the knowledge of the Recipient Entity, no condition exists under

the Agreement that would allow NVTA to withhold the requested advance.

RECIPIENT ENTITY

By:

____________________________________

Name: ____________________________________

Title: ____________________________________

Recommended For Payment

By:

____________________________________

Name: ____________________________________

Title: NVTA Program Coordinator

Form Of Requisition

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