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COPY <br /> DR- 4169 -OR PAYMENT REQUEST FORM <br /> SMALL PROJECTS (UNDER $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 /> C;--y en perjury that the items and totals listed herein are proper <br /> Vb20 RooSC.4,1+ Blvd , charges for materials, merchandise or services to the <br /> �� / o - �7�� State of Oregon, and that all goods furnished and /or <br /> services rendered have been provided without discrimin- <br /> 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 La c'e`t P;&A,f, <br /> Print Authorized Agent's Name <br /> PA ID (FIPS) Number: 039- 23850-- Dc <br /> 11 latAdAli <br /> PW Number: 2.2-. Signature of Authorized Agent <br /> Category: B � � � al vrAarih o r -Pk) C l z &l (ef <br /> Title u Date <br /> Federal Tax ID Number X13-- (.00011-00 Duns # X13 50 t <br /> A. 2- Amount Eligible (100 %) <br /> B. -O, 5$8.91 Federal Share <br /> OEM USE ONLY: <br /> PCA: <br /> Object: <br /> Payment #: Payment Amount: <br /> Prepared By Date OEM Approval Date <br />