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ILLINOIS ENVIRONMENTAL PROTECTION AGENCY/BUREAU OF WATER <br /> Request for Loan Disbursement From the Water Revolving Fund <br /> Borrower: <br /> Loan#: <br /> Date: <br /> INSTRUCTIONS: Use this form when making a request for State loan disbursements. One form must be <br /> submitted each time you request a disbursement. <br /> Loan Disbursement Calculation: (Please report TOTAL CUMULATIVE costs incurred to date and submit <br /> copies of all supporting invoices.) Please identify, if any, the costs that are being paid with other funding sources. <br /> Total Cumulative Costs Tot. Cumulative Eligible <br /> Incurred to Date Costs Incurred to Date <br /> Legal <br /> Design Engineering <br /> Construction Engineering <br /> Construction <br /> Other: <br /> Total Costs Incurred to Date <br /> Less: Paid with other Funding Sources <br /> Less: Total Interest Earned on Invested Funds <br /> Less: Total Disbursements to Date <br /> NET DISBURSEMENT REQUESTED <br /> Your Current Loan Fund Status (Totals to Date) <br /> Disbursements Received & Deposited in Fund: <br /> Expended from Fund: <br /> Interest Earned on Fund: <br /> Current Fund Balance: <br /> FOR AGENCY USE ONLY <br /> Prepared by Date <br /> Approved by Date <br /> Yes No <br /> EFT requested <br /> Revised March, 2001 <br />