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DEPARTMENT OF ENVIRONMIENTAL PROTECTION <br /> BUREAU OF RESOURCE PROTECTION <br /> PAYMENT REQUISITION <br /> LOAN No. 00-50-B REQUEST No. 17 <br /> DMS PROJECT NO._CWSRF 581 <br /> LEGAL NAME AND ADDRESS OF BORROWER: PAYABLE TO: <br /> Town of Mashpee Town of Mashpee <br /> 16 Great Neck Road North <br /> Mashpee, Massachusetts 02649 <br /> PAYMENT METHOD: WIRE TRANSFER <br /> ACCOUNT#: Rockland Trust CO. #4035097 <br /> APPROVED PREVIOUS THIS <br /> EXPENDITURE TYPE AMOUNT REQUESTS REQUEST <br /> Technical Expense 170,286.00 $100,723,52 $1,180.00 <br /> Technical Expense 19,939.00 $8,356.00 $0.00 <br /> Totals $ 190,225.00 $ 109,079.52 $ 1,180.00 <br /> CERTIFICATION OF THE BORROWER: <br /> The Authorized Representative ofthe Borrower identified below certifies the following: <br /> (j)This payment is for Project Costs and the obligations specified herein have not been the basis for a prior requisition that has been paid; <br /> (ii)there has been no Default,as defined in the Regulatory Agreement hereunder or no Event of Default as defined in the Loan Agreement, <br /> and no event or condition exists which after notice or lapse of time or both,would become a Default under the Regulatory Agreement <br /> or an Event of Default under the Loan Agreement exists;and <br /> (iii)the payment requested by this requisition is due for work actually performed or materials or property actually supplied prior to the date of <br /> of this requistion less retainage. <br /> Signatu- r ate: <br /> Print Name:T�.� om`as Fu ala <br /> Title:-Chairman, Sewer Commission <br /> (To be completed by the DEP Division of Municipal Services) <br /> Amount Requested: Amount Approved: <br /> Signature: Date <br /> Print Name: <br /> Title: <br /> FORM BMF-1000 <br />