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Workforce Housing Development Program <br />Payment Information <br />Summary <br />This form must be completed, signed and submitted to MHFAprior to receiving a disbursement of funds. To <br />complete the form, enter the amount of funds you are requesting and a summary of what the funds will be <br />used for. Have the form signed by an AuthorizedRepresentative. Submit the completed form to Sara Bunnat <br />sara.bunn@state.mn.us. <br />Disbursement Request and Justification <br />Amount Requested (not to exceed one-third of the total award): <br />Use the space below to document what the funds will be used for: <br />Authorized Representative Signature <br />Authorized Representative Name: <br />Authorized Representative Title: <br />Date Signed: <br />Authorized Representative <br />Signature: <br />9 <br />October 2021Workforce Housing Development Program Competitive Grant Agreement <br />