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Michigan Department of Treasury
4923 (03-12)
Economic Vitality Incentive Program (EVIP) Grant Payment Request
Issued under authority of Public Act 63 of 2011, as repealed and replaced by Public Act 278 of 2011.
SEE PAGE 2 FOR INSTRUCTIONS TO COMPLETE THE REQUEST
PART 1: PROJECT INFORMATION
1. Grant Number
2. Project Title
3. Request Number
4. Period Start Date
5. Period End Date
6. Request Type
7. Primary Local Unit FEIN
Partial
Final
8. Primary Local Unit Name
9. Telephone Number
10. Payment Mailing Address
City
State
ZIP Code
PART 2: EXPENDITURE DETAIL
A. Budget Category
B. Total Expenditure
C. Percentage
D. Amount Incurred this
E. Amount Incurred to
Incurred for Period
Funded
Period
Date
$0
25%
11. Feasibility Study
$0
100%
12. Contracted Services
$0
100%
13. Administration
$0
100%
14. Training
$0
100%
15. Merger Expenses
$0
50%
16. Infrastructure/Equipment
$0
100%
17. Other
18. ADJUSTMENTS DUE TO OTHER FUNDING - Reimbursements by other funding
(
)(
)
sources or the use of cash on hand
$0
19. TOTAL AMOUNT INCURRED THIS PERIOD - Sum of the amounts shown in Column D
20. TOTAL CUMULATIVE AMOUNT INCURRED TO DATE - Sum of the amounts shown in Column E
(
)
21. AMOUNT PREVIOUSLY DISBURSED - Line 22 on the previous payment request form
22. AMOUNT REQUESTED FOR DISBURSEMENT - Subtract Line 21 from Line 20
PART 3: CERTIFICATION
I hereby certify that the information in this request is complete and accurate and all expenditures for which reimbursement is requested are for eligible
scope items as defined in the Final Grant Award Letter for the above project, and that all expenditures have been made during the project period as
listed in the Final Grant Award Letter, and are identified and filed according to accounting procedures set forth by the Michigan Department of Treasury.
Printed Name of Primary Local Unit Chief Financial Officer
Title
Signature of Primary Local Unit Chief Financial Officer
Date