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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. I hereby certify under penalty of <br /> of �ltQP�'1e perjury that the items and totals listed herein are proper <br /> of 7 �/ �J charges for materials, merchandise or services to the <br /> L 2.D '1ZOO5�/at Blvd . State of Oregon, and that all goods furnished and /or <br /> Eugeytc , OR. • 17'++2_ services rendered have been provided without discrimin- <br /> C� 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 Lac .N 4 , o I <br /> Print Authorized Agent's Name <br /> PA ID (FIPS) Number: O39 - 2356 - Op <br /> bQ 0 A Q.0c1, -OL <br /> PW Number: LO - ( Signature of Authorized Agent <br /> Category: A 7, --name 0 t yY\nn rLcac r - 14) 13 k <br /> Title Date <br /> Federal Tax ID Number: c/3- (,002.1[00 Duns # 93- 124013o <br /> Type of Request: Project Costs: <br /> A. t 7 3 , Co 4-7 \ 5 Total Project Costs to Date <br /> B. — Less total costs previously claimed <br /> Progress Payment <br /> t/ Final Payment C. i Lttp, qq2. 52 100% 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 /> t <br />