STATE OF MISSISSIPPI GOVERNOR PHIL BRYANT

DEPARTMENT OF FINANCE AND ADMINISTRATION LAURA D. JACKSON

EXECUTIVE DIRECTOR

Quarterly Report for Bond Proceeds

Name of Entity: _______________________________________________________________________________________________

Project Description: __________________________________________________________________________________________

Authorizing Legislation: _____________________________________________________________________________________

Report for the Quarter Ending: March 31 September 30 For the Year: _________________

June 30 December 31

Report Type: Initial Quarterly Final

Please complete only upon initial receipt of funding

Initial Receipt of Bond Proceeds (__________________): $_________________________________

Less: Pro Rata Share of Issuance Cost (if applicable): ($________________________________)

Beginning Project Balance: $_________________________________

Beginning Quarterly Balance (__________________): $__________________________________

Less: Quarterly Project Expenditures: ($________________________________)

Ending Quarterly Balance (__________________): $__________________________________

Project Update Summary (please supply a quarterly update regarding status of project):

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

Revised August 2017

I, the undersigned authority, do hereby swear and affirm that all information provided above is

complete and accurate to the best of my knowledge. I further swear and affirm that all State bond

proceeds reported on herein were used in accordance with the legislation that authorized such bonds.

Authorized by:

________________________________________________________ Name

________________________________________________________ Signature

________________________________________________________ Title

________________________________________________________ Date

Sworn to and subscribed before me this ________________day of______________________, 20______

State of MississippiCounty of: _____________________________

Notary Public _________________________________________________________My Commission Expires _____________________________________________

Notary Public

Seal

Revised August 2017