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STATE OF OREGON PARKS AND RECREATION DEPARTMENT <br />REQUEST FOR GRANT REIMBURSEMENT <br />~ <br />Gram T ^ LWCF ^ AN- <br />~ R'iP ^ local Gov, ^ RV ^ Veteran's <br />Pro"edS nsor: .G ~.'-` ~ Proled# - <br />Pro'ed Name: ¢nR ra J'Lr~JA <br />~ <br />Dale Work Started: <br />4 Billing Period: l-1 D ~~ ~ sQ to <br />Date of Approval: t, ' Billing# 2. .Billing: Pardal Final <br />Pro ect /Grant Summary (Per A reement) Comments: <br />rant Amount 5' <br />SponsorsMatch Percentage <br />Sponsors ContdbuGons - - ~ ~ <br />mum a em ursemen p, pp <br />'DETAIL. PROJECT COSTS <br />TYPE OF EXPENSE Costs Inwrr <br />e <br />d This Pedod Cost <br />Previousry Billed .Total Project Costs to Date <br />Salaries and Wa es Age Force Acmunt) ~- ~ <br />y <br />~ S.~ 7 1 <br />~ 1 ~~ c~~ ~ %(; ~- 1 , <br />Contract Pa menls y j jr~ '~ ~ ~ ~j ~ t, <br />E ui ment Rental (l'hmeNOutgde) ~ - <br />~ <br />Materials andSu lies - Z ( <br />y Dj ~- ` <br />u CJ J, <br />Consultant Services Dea' rEn Inaed ~ ~ Z '~ ,~j _ <br />J Z '~-~ <br />Value of Approved Donations <br />(Deneletl labor, meledsls erM ui nl <br />roved Pr reement Costs <br />Real Pro Costs <br />Other <br />Otlter <br />Other <br />Other <br />Other <br /> <br /> <br /> <br /> <br /> <br />A: TOTAL PROJECT COSTS I , { S S Z. } Z I Z (i j 2. <br />B. Less Costa in E:rasa of A reement 9 5 6 5 3 2 <br />C. TOTAL ELIGIBLE COSTS L 'Z to ZO I ~ 1 c ~ -, a t> <br />cM~n qy c ey Raeyeirad n>ata, %) I k Z `I I . ,~ <br />'Z K5- S`f <br />~o`~-~ - 3~ <br />(C minus D=E) - T (,II <br />Z~v1Z •CZ 3~ ~ ~ ~ 7 <br />Doc mentadon Su Mn Ex endlturea and Match will be wired for eve Re/mbursement. <br />I certify that this billing is correct and Is based on actual costs inwmetl and can be supported with tlocumentation on file with the sponsor. <br />I also certify that the work and services whkh have been parformetl to dale are in accordance with the approved project agreement including <br />amendments thereto; and that this Sponsor has complied with al applicable State and local statutes. <br />I agree to retain records pertainirg to this billing for three years~past the project completion date. <br />I certify that this Sponsor, is not involved in any court lifigafan or lawsuR wherein it is alleged by pdvate parties of the United States that person <br />were, on the grounds of rece, color, or natural ortgiri exduded from partidpafion in, denied benefns of, or otherwise subject to discrtminafionin <br />the programs or fa 'liges of th//is SponsAor ' <br />Signature: ~ G` l~U~~^ Date: b ~ ~ I U D <br />Contact: ~ b Telephonetl 65 -~b~ <br />