I-2 - Economic Development Grant Agreement - Honey Lane Development

EXHIBIT C FORM OF GRANT DISBURSEMENT REQUEST Date submitted: Submitted by: Contact information: Index of Invoices/Statements Attached to substantive request: I, the undersigned hereby certify that the costs shown on the documents referred in the index above are legitimate costs reasonably incurred in the undertaking of Public Infrastructure Project. HONEY LANE DEVELOPMENT, LLC By: [Name, Title] Reviewed and accepted by the City of Tiffin, Iowa this day of ,20| By: City Administrator -7- 4894-5915-9757\2