Phone: 321-633-2016
Email: IRLProject@BrevardFL.gov
Website: www.BrevardFL.gov/SaveOurLagoon
GRANT REIMBURSEMENT REQUEST
Grant approval and reimbursement of costs are contingent upon the private sewer lateral cleanout
portion being brought up to a satisfactory and serviceable condition free of defects and in compliance
with the County’s Code. The actual grant amount for reimbursement shall be limited to the
contractor’s charges and within the reimbursement limits defined, which shall be subject to review and
approval by the District under the program terms. In order to process your reimbursement, you must
provide the following information:
Briefly describe the private sewer lateral cleanout work that was completed:
____________________________________________________________________________________
____________________________________________________________________________________
Accompanying Documentation
W-9 Form
Vendor Request Form
Permits
Inspection Approvals
Invoices & Receipts
All receipts must be provided to be eligible for reimbursement.
Inspection Cost: $_______________
Repair or Replacement Costs: $_______________
Total Requested Grant amount: $_______________, not to exceed $2,000
Property Owner
I/WE hereby apply for the grant reimbursement shown above;
I/We agree to abide by the terms and conditions of the Save Our Indian River Lagoon Project Plan
Private Sewer Lateral Grant Program;
I/We hereby certify that the information given herein and on the program application is true, correct
and complete in every respect and may be verified by Brevard County;
Property Owner(s) Names: ____________________________________________________________
Property Address: ___________________________________________________________________
Signature of Property Owner(s): __________________________________ Date: _______________
