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�oioo�s3� EXHIBIT D REQUISITION FORM Owner Name and Address: Pursuant to, and in aecardance with, the provisions of the Section 1602 Subaward Agreement, dated , 2010 (the "Agreement"), l�etween the Nebraska Investment Finance Authority (the "Authority"), and Ridgewoad CROWN, I,LC (the "Owner"), the Owner hereby requests the Autharity ta disburse to the Owner the sum pf $ . IT IS HEREBY CERTIFIED THAT: 1) None of thc iterns for which disbursement is requested has formed thc basis for any disbursement heretafore madc under the Agreernent; 2) The Owner has no notice of, and is not otherwise aware of, any mechanics', materialmen's, laborers', suppliers', vendars' or other liens or rights in respect therepf which should, in accordance with the Agreement, be satisfied �r drscharged before this disbursennent is made; 3) This disburserncnt does not include any atnount which the Owner is entitled to retain pursuant to any contract or agxeernent providing for the retention by the Owner nf a portion of the price paid thereunder; 4) No Event of Default is continuing under the Agreement; and 5) Attached hereto are each of the follawing: a) Attachment 1: An iternization af bills and invaices tp be paid with the requested disbursement tagether with copies pf all such bills and invoices; b) Attachznent 2; A Contractor's Swom Statement tagether with supporting mechanics lien waivers signed by Owner's Contractor (Note: a Contractor's Sworn Staternent and supporting mechanics lien waivers shall not be required prior to the initial disbursement of 1602 funds). c) Attachrnent 3: An AIA inspection report signed by a]icensed architect in support of the draw request indicating that all work and rnaterials to be paid for with�the disbursement have been furnished in accnrdance with the Plans and Specifications; OWNER: RTDGEWQOD CROWN, LLC By: Housing Plus, LLC Date: Narne, Title a�4i-zi3s-3a7s.z