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201007863 M�:�:Mi:��7 REQUTSTTION FORM Or�mer Narne and Address: Pursuant to, and in accordance wiCh, the provisions o�' the Section 16Q2 Subaward Agreem�nt, dated , 2010 (the "Agreemen�'), betWeen the Nebraska Investment Finance Authority (thc "Authority�'), And Mosaic Residendal Services of Nebraska, LLC (the "Owner"), the �wner hereby rcquests the Authority to disburse to the Owner thc sum of $ IT IS kIEREBY CERTYFYED THAT: 1) None of the items for which disbursement is requested has formed the basis for any disbursement heretofore made under the Agreement; 2) Th� Owner has no notice af, ar�d is not otherwise aware of, any mechanics', materialrnen's, laborers', suppliers', vendors' or other liens or rights in respect thereof which should, in accordance with the Agreement, be satisfied ar disCharged before this disbursement is made; 3) This disburscrnent does nat include any amount which the Qwn,ec is entitled to retain pursuant to any contract or agreement providing for the retention by the Qwner of a portion of the price paid thereunder; 4) No Ev�nt of Default is continuing unde�r the Agreement; and S) Attached hereto are each pf the fallowing: a) Attachment 1: An itemization of bills and invoices to be paid with the requested disbursement togethcr with copies of all such bills and invoices; b) Attachment 2: A Contrgetor's Sworn Statement together with supporting xnechanics lien waivers signed by Owner's Contractor (Note: a Contractor's Sworn Stacement and supporting mechanics lien waivcrs shall not be required prior ta the irutial disbursement af 1b02 funds). c) Attaehment 3: An AIA inspection report signed by a licensed architect in suppart of the draw request indicating that a11 work and materials to be paid for with the disbursement have t►een furnished in accordance with the Plans and Specifications; C�L%�I�i� '.7 MOSAIC RESIDENTIAL SERVICES OF NE$RASKA, LL� Sy MOSAIC, its managing member Date: Name, Title asas-2a3z-ia9a.z