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STATE OF OREGON PARKS AND RECREATION DEPARTMENT <br /> REQUEST FOR GRANT REIMBURSEMENT <br /> Grant Type ❑ t.w F ❑ ATV RTP ❑ Local Gov, ❑ RV ❑ Veteran's <br /> Project Sponsor: (i QP Ee • e; Ky ., i 006 cc 'Project # <br /> Project Name: ekt9(Li TCRti.rla ) s"`"0 1krefett `t'S <br /> Date Work Started: (-4 b !Billing Period: L / j iii 3 /31 I O lor <br /> Date of Approval: '..j / Billing# ( 'Billing: Partial &nal <br /> Project / Grant Summary Comments: <br /> ry (Per Agreement) <br /> Grant Amount $ i C I L t55 - <br /> Sponsors Match Percentage } : S <br /> Sponsors Contributions $ 3 i i a , G 0 <br /> Maximum State Reimbursement $ i r 0.. J <br /> r <br /> DETAIL. PROJECT COSTS <br /> TYPE OF EXPENSE Costs Incurred This Period Cost Previously Billed Total Project Costs to Date <br /> Salaries and Wages (Agency Force Account) l ) I 1 4 QZ) I I (11 00 <br /> Contract Payments 3 O g l) $ . ..) 3 0 c O v <br /> Equipment Rental (Owned /Outside) <br /> Materials and Supplies , 4-3 , t 9 3 Lt 4-3 I ct <br /> Consultant Services (Design /Engineering) Z Lel 12..141 r c1 <br /> Value of Approved Donations <br /> (Donated labor, materials and equipment) <br /> Approved Pre - Agreement Costs <br /> Real Property Costs <br /> Other <br /> Other <br /> Other <br /> Other <br /> Other <br /> A. TOTAL PROJECT COSTS 572-0, I I (R- S (7-0 L . t B. Less Costs in Excess of Agreement <br /> C. TOTAL ELIGIBLE COSTS S t 7- S a Lot . ) - 7- <br /> D. S Match <br /> r� 2l , S c' <br /> (Multiply iply C C b by Required Match %) 2� i � Sy <br /> E. TOTAL REIMBURSEMENT REQUEST 2 <br /> (C minus D=E) 3� 31 3 36 34L-4. <br /> Documentation Supporting Expenditures and Match will be required for every Reimbursement. <br /> I certify that this billing is correct and is based on actual costs incurred and can be supported with documentation on file with the sponsor. <br /> I also certify that the work and services which have been performed to date are in accordance with the approved project agreement including <br /> amendments thereto; and that this Sponsor has complied with al applicable State and local statutes. <br /> I agree to retain records pertaining to this billing for three years past the project completion date. <br /> I certify that this Sponsor, is not involved in any court litigation or lawsuit wherein it is alleged by private parties of the United States that persons <br /> were, on the grounds of race, color, or natural origin excluded from participation in, denied benefits of, or otherwise subject to discrimination in <br /> the programs or fa ies of this Sponns r. <br /> Signature: Date: - -2. I C Is <br /> Contact: ° 7e-s5E C - I4c 35 Telephone# 5 E C 5 2 - <br /> . 4` +- . ``°5 t'i - �..£•- i` '`: s - p^s M - V <br /> E- £S _ k� � .rx+ �,� fi r . �? btu � '7. °,S " „c _�+ 'r's�`' ,�h"`�..ss. <br /> .� Y �- y $�y'° ate+ i" "�' a 3,f31'3'�"'`'�^�3'`y�sY -� �° �.= s ' ` $' `=�� -. " � • -r �"��'e�� +if x` <br /> J � `� � � t Y . . . Z d.+ ✓tit.. > f, t-� D `xa # <br /> ^�..' ..s.. a.`L ��..a,,.3,5. '�a���#� v�'e'' �s; <br /> 140 n � b„ � . <br /> ".`�.. - ln!Jd1!-.w• "] Yv3�eaF+., F.` i ,a''ieY.'w'TwT.i:m�'`�a�'Fe.,i' i _ "`. �i:'G( @S +- ey+4.. ... 'V <br />