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STATE OF OREGON PARKS AND RECREATION DEPARTMENT '' <br /> REQUEST FOR GRANT REIMBURSEMENT <br /> it..., ,... <br /> Grant Type ❑ LWCF ❑ AN ] RTP ❑ Local Gov, LI RV ❑ Veteran's <br /> Project Sponsor: a4rL g E;;�p, PA K r ( y tLQ _Project# <br /> Project Name: (,): PL_A-C (A3s�fir t;1i _ ` - V CCGA ) T <br /> Date Work Started: ` P-I- ` +q, Billing Period: LI i F / D4, 4 / 5"/ c.1 to <br /> Date of Approval: Z1,:.5 (0.4 Billing# 2.. 'Billing: / ),< , Partial r] Final <br /> Project / Grant Summary (Per Agreement) Comments: <br /> Grant Amount $ 101 `i c 5 <br /> Sponsors Match Percentage -31.., 5 5 <br /> Sponsors Contributions $ 3 y <br /> Maximum State Reimbursement $ 43 5 - 00 <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) S C-5- 9 - • L4 ' 111P y , U `� 1 41 6'9 1 • 1 <br /> Contract Payments r ? It,5 , 4' 1.0 c9' . ()u S230'51 • 5 , <br /> Equipment Rental (Owned /Outside) <br /> Materials and Supplies Si ^ Z � .. (5 3 `� /:3 j ( r `'I 0 fI . 7 ) '-j <br /> 3 3 Consultant Services (Design /Engineering) I : ' ` -2 -- -' VI .'1( I H 2 - 7 .-2 . <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 (; a, . I C I . t C3`°' S q 0 ( • I . I Z I U 2 c' • 7 <br /> B. Less Costs in Excess of Agreement (t\ ` .5 (. 5' . j 2., <br /> C. TOTAL ELIGIBLE COSTS L! ?j 2 c . _ L g L o I t I O ( L l c4)----• v t) <br /> D. Sponsor Match r 7 <br /> (Multiply C by Required Match %) 1 k 7, tk ( ' 7 ; 1 2A � `� , S' , ) i g 0 <br /> E. TOTAL REIMBURSEMENT REQUEST 2 <br /> (C minus D =E) 1 (7 , 12,0- 33L , & J 3 'J , 63 - <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 fifties of this Sponsor. • <br /> 11 I <br /> Signature: K t/ i'�~ D ate: 4' i <br /> Contact: 5 - (e - f -hh Telephone# � ') Z -' 3 <br /> 4¢[ ti- ' t ' ,: :" s ' �x .• tar �„�+_. f'.�.: 'y„` i prs 3 +-`1• Y4 t <br /> r a`t JS 3rd --zx rr r 'k .i" "t r• <br /> ,` g # $, �r1 -23T• - F. .c b l ��`,t .. f J ? Y 3 i Y '� F.t: �. ' f •N;:p <br /> ', : 's� `Y text 3 4 . Y '.`-c> =.k, 'l a 't s S.�, i t , c..s.• '-,a ' 'af41* ^i °< a i : <br /> e� 7�� °' 1.z R 1 -. '.� f :: - . $.ic- �:�.c:..��s'.9xn. vu. _.:..»��....rG .i.'°§�. ._ ' Li,l` _filJ� J�.�� ., I.0 -.� ._ -.. _ � in <br />