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TOBACCO TRUST FUND COMMISSION • <br /> EXHIBIT C, FINANCIAL REQUEST FORM _ _ ___ _ PURPOSE FOR FILING (CHECK ONE) . <br /> • #REQUEST FOR FUNDS �� (QUARTERLY REPORT <br /> Date: <br /> Project Number: TTFC Grant Amount: <br /> Grant Recipient: Payment Request Number: <br /> Project Title: Amount This Request: $0.00 <br /> Signature of Chief Financial Officer <br /> A B C D E F G <br /> Itemized Expenditures as Shown in Exhibit A, TTFC Budget as TTFC Amount Amount of TTFC TTFC Amount This Total Requested Unrequested TTFC Funds <br /> Scope of Services Shown in Scope of Previously Funds Expended To Re uest TTFC Funds Remaining(Columns B <br /> Services Requested Date q (Columns C plus E) minus F) <br /> 0 0.00 0.00 <br /> 0 0.00 0.00 <br /> 0 0.00 0.00 <br /> 0 0.00 0.00 <br /> 0 0.00 0.00 <br /> 0 0.00 0.00 <br /> 0 0:00 0.00 <br /> 0 0.00 0.00 <br /> 0 0.00 0.00 <br /> 0 0.00 0.00 <br /> 0 0.00 0.00 <br /> 0 0.00 0.00 <br /> 0 0.00 0.00 <br /> 0 0.00 0.00 <br /> 0 0.00 0.00 <br /> 0 0.00 0.00 <br /> 0 0.00 0.00 <br /> 0 0.00 0.00 <br /> 0 0.00 0.00 <br /> 0 0.00 0.00 <br /> Totals $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 <br /> NOTE:If any amounts in column G are ne l ative,contact the TTFC immediate) . <br /> Amount Expended rah `" �� Y, t ," <br /> List other revenue sources for this project � . Y _ � <br /> fe$, ; p ; H ) ;",•';"1791.!".;';ddi i x r tli ,\,M If ,, <br /> ai d. : I 1s } ) L. ' *:,:.if; i {} '#?# . i, hz.s�tti.a 7,,47,- "r v <br /> TOTAL <br /> Revised 11-2008 <br />