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DR- 4169 -OR PAYMENT REQUEST FORM <br /> LARGE PROJECTS ( Over $120,000) <br /> State of Oregon <br /> AGENCY NAME INSTRUCTIONS TO SUBGRANTEE: Submit this form to <br /> Oregon Emergency Management claim payment for reimbursement of costs associated <br /> PO BOX 14370 with the repair or restoration of damaged facilities <br /> Salem, OR 97309 - 5062 documented on the Damage Survey Report. <br /> SUBGRANTEE (warrant to be payable to) Subgrantee's Certificate. 1 hereby certify under penalty of <br /> Cif 0� perjury that the items and totals listed herein are proper <br /> f charges for materials, merchandise or services to the <br /> �S2.0 'RODS= 81vd • State of Oregon, and that all goods furnished and /or <br /> tL erie , OR 'T71+0Z services rendered have been provided without discrimin- <br /> �J1 ation because of age, sex, marital status, race, creed, <br /> color, national origin, handicap, religion, or Vietnam era <br /> or disabled veterans status. <br /> Disaster Number: DR- 4169 -OR acie,l <br /> Print Authorized Agent's Name <br /> PA ID (FIPS) Number: Q - g— 23550 -on <br /> (ch,rr. P k\Q L 1 <br /> PW Number: CO Signature of Authorized Agent <br /> Category: A 1::• r anriyer Pw <br /> Title Date <br /> Federal Tax ID Number: q3— (eCQ Duns # 95 I <br /> Type of Request: Project Costs: <br /> A. 3 3, . • . Total Project Costs to Date <br /> B. -•• Less total costs previously claimed <br /> V Progress Payment <br /> Final Payment C. 313-, aact. . 3 100% of costs claimed on this request <br /> (A -B) <br /> OEM USE ONLY: <br /> PCA: Applicant Expenditure amount: <br /> Object: <br /> Payment #: Payment Amount: <br /> Prepared By Date OEM Approval Date <br />