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TOBACCO TRUST FUND COMMISSION <br />EXHIBIT C, FINANCIAL REQUEST FORM _ _ _ _ __ PURPOSE FOR FILING C_H_E_CK ONE) <br />~ ~ ~ ~ ~ ,REQUEST FOR FUNDS ~~ ~~~~~~ <br />r iQUARTERLY REPORT <br />Number: <br />Title: <br />Signature of Chief Financial Officer <br />A B <br />Itemized Expenditures as Shown in Exhibit A, TTFC Budget as <br />Scope of Services Shown in Scope of <br />Services <br />Totals ~ $0.00 ~ <br />i~vic: a any amp <br />Amount Expended <br />List other revenue sources for this project <br />TOTAL 0.00 <br />TTFC Grant Amount: <br />Payment Request Number: <br />Amount This Request: <br />C D E F G <br />TTFC Amount <br />Previously <br />Re nested <br />9 Amount of TTFC <br />Funds Expended To <br />Date <br />TTFC Amount This <br />Request Total Requested <br />TTFC Funds <br /> <br />(Columns C plus E) Unrequested TTFC Funds <br />Remaining (Columns B <br /> <br />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 />$0.00 $0.00 $0.00 $0.00 $0.00 <br />.. v a.c ucga^^.cy cvmac^ ^uc a arm, uwucu~a~cry. <br />` }Y~ '~'-.d- 4 L F : S y ~ ~ r:.« '. ~~t_ ,.- T 4',~''r f:" s ~ ,..~ Y ''~ y~, y - <br />~I~a~~httaCl;~allrlnvdlces/documentation to substantiake~ou~t'~eghesr•fo futtd~ '~ -~ <br />.i yi ".c~ ~t f#~ !~ ~.~fic,.r t' L ,. ~.YT Y ~"1 n Ls 'Y.' .~.~. ..~,.`.~~h' c~ 7 <br />~ ~ ~,. <br />,. <br />•, <br />,~ <br />t. v- ~.: ~ ...,i ;•, bra t,,~.v r;, ~- <br />°Signature of the Flnanclal;Offieer'on this,document certlfies,tt~~t the~work for which funds~are <br />.._ - - . <br />`egtlested has l3eehdo,ne~consistent-with the Scope_of Services: ~~ ~Kf ~ - - ~' <br />}~ ~ ~~~ <br />Revised 11-2008 <br />