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c �' <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 /> perjury that the items and totals listed herein are proper <br /> CI OF gene charges for materials, merchandise or services to the <br /> Ie.2.0 ROp50/61-I' 13IVd • State of Oregon, and that all goods furnished and/or <br /> a43ene , op, 61-11+02. 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 Lac.e P i .5c& k <br /> Print Authorized Agent's Name <br /> PA ID (FIPS) Number: 039 - 2.3S60 - 00 <br /> et r D, <br /> PIN Number: 2J Signature of Authorized Agent <br /> Category: C.- , nQ►•�a l v - ? w 0 /31, /iy <br /> Titlb Date <br /> Federal Tax ID Number '13 0Ob2I tpD Duns # I2-cirtso 1 <br /> A. 15, 2.ei l . 2-4p Amount Eligible (100 %) <br /> B. # I:i, L f(oS • 45 Federal Share <br /> OEM USE ONLY: <br /> PCA: <br /> Object: <br /> Payment #: Payment Amount: <br /> Prepared By Date OEM Approval Date <br />