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STATE OF OREGON PARKS AND RECREATION DEPARTMENT <br />REQUEST FOR GRANT REIMBURSEMENT <br />Veteran's <br />LWCFATVRTPLocal Gov. <br />COGP / RV <br />Grant Type <br /> RT12-007 <br />Project # <br />City of Eugene <br />Project Sponsor: <br /> Spencer Butte Summit Trail <br />Project Name: <br />January 1, 2013January 1, 2014 to June 30, 2014 <br />Date Work Started: Billing Period: <br />Billing# 1 <br />Date of Approval:Billing: <br />PartialFinal <br />Comments: <br />Project / Grant Summary (Per Agreement) <br />Total Project Cost <br />$193,742.00 <br />Sponsors Match Percentage <br />49% <br />Sponsors Contributions$95,000.00 <br />98,742.00 <br />Grant / Maximum State Reimbursement <br />$ <br />DETAIL PROJECT COSTS <br />TYPE OF EXPENSE <br />Costs Incurred This Period <br />Cost Previously BilledTotal Project Costs to Date <br />Salaries and Wages <br />(Agency Force Account) <br />Contract Payments <br /> 9,995.00 9,995.00 <br />Equipment Rental <br />(Owned/Outside) <br />Materials and Supplies <br />Consultant Services <br /> (Design/Engineering) <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 9,995.00 - 9,995.00 <br />B. Less Costs in Excess of Agreement <br /> - - - <br />C. TOTAL ELIGIBLE COSTS 9,995.00 - 9,995.00 <br />D. Sponsor Match <br /> 4,897.55 - 4,897.55 <br />(Multiply C by Required Match %) <br />E. TOTAL REIMBURSEMENT REQUEST <br /> 5,097.45 - 5,097.45 <br />(C minus D = E) <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 is supported by documentation on file with the sponsor and <br />submitted with this form. <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 all applicable State and local statutes. <br />I agree to retain records pertaining to this billing for six 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 <br />persons were, on the grounds of race, color, or natural origin, excluded from participation in, denied benefits of, or otherwise subject to <br />discrimination in the programs or facilities of this Sponsor. <br />Signature: Date: 07/11/2014 <br />Telephone: 541.682.4888 <br />Contact: Trevor Taylor <br />For OPRD Use Onl: <br />y <br />Authorized Payment by:____________________________________________________________ Date:_____________________________ <br />Amount of Admin Costs (LWCF)__________________ <br />Amount of Reimbursement: $_____________________________ <br />