Packet: Regular City Council Meeting (11/04/2025)

EXHIBIT B 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 -6-