New Search
6.3 AGENCY BILLING FORM - REQUEST FOR REIMBURSEMENT <br /> Local Government Grant Program <br /> PROJECT SPONSOR: PROJECT No. BILLING No: # <br /> ❑ PARTIAL ❑ FINAL <br /> PROJECT NAME: <br /> DATE OF PROJECT APPROVAL: DATE WORK STARTED: <br /> DETAILS OF PROJECT COSTS COSTS INCURRED COSTS BILLED TOTAL PROJECT <br /> THIS PERIOD PREVIOUSLY COSTS To DATE <br /> SALARIES AND WAGES $ $ $ <br /> CONTRACT PAYMENTS $ $ $ <br /> EQUIPMENT, MATERIALS & SUPPLIES $ $ $ <br /> PROGRAM ADMIN., DESIGN & ENGINEERING $ $ $ <br /> VALUE OF DONATIONS $ $ $ <br /> OTHER $ $ $ <br /> OTHER $ $ $ <br /> A. Total Project Costs $ $ $ <br /> B. Less Costs That Exceed Match $ $ $ <br /> C. Total Costs Eligible for $ $ $ <br /> Reimbursement <br /> D. Multiply C by Required Match <br /> Amount (50% OR 40 %) $ $ $ <br /> E. TOTAL REIMBURSEMENT REQUEST <br /> (C minus D = E) $ $ $ <br /> I certify that this billing is correct and is based upon actual costs incurred during the project period and can be <br /> supported by documentation by this agency. <br /> I also certify that the work and services that have been performed to date are in accordance with the approved project <br /> agreement including amendments thereto; and that this agency has complied with all applicable state, local and <br /> federal statutes. <br /> I further certify that this agency, is not involved in any court litigation or lawsuit wherein it is alleged by private parties <br /> of the United States that persons were, on the grounds of race, color or natural origin are excluded from participation <br /> in, denied benefits of, or otherwise subject to discrimination in the programs or facilities of this agency. <br /> Signature of Agency's Authorized Representative Title Date <br /> Name of Person to Contact for Audit Address Telephone No. <br /> FOR OPRD USE ONLY <br /> Date: Authorized for Payment by: EA/Enc. <br /> Amount: <br />