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STATE OF OREGON PARKS AND RQCREATION DEPARTMENT <br />REQUEST FOR GRANT REIMBURSEMENT ATE <br />Grant T e ^ LWCF. ^ AN - RTP ^ Local Gov, ^ RV ^ Veteran's <br />Pro edS nsor.. Ci OF Eo ~ ~ a,.J- L'~ Projeq# <br />Project Name:Ql Q_ nQ_ n ;n~ tU1eq n~.Q-uVernt <br />Date, Worn Started: 0 Billing Period: I O $ ~- ~ 31. D Y <br />Date of Approval: L ~ Billing# I ~ - Billing: Partial anal <br />Project /Grant Summary (Per Agreement) comments: <br />Grant Amount -0 <br />S nsors Match Percentage ~, , $,f. _ <br />Sponsors Contributions - ~ $ i 0 . o <br />aximum a eim arsemen 3 ,~ , c, <br />'DETAIL PROJECT COSTS <br />TYPE F EXPENSE - Costs Incurred This Periotl Cost Previously Billed Total Project Costs to Date <br />Salaries and Wa s A Force AccarnQ - 114 . Q(~ ~ ~ I I y r O c7 <br />Contrail Payments t7 , Jc7 ~ ~ O ~ <br />E ui merit Renlel (OwnerLOulsida) <br />Materials and Su lies ~ t{ <br />ConsUltaml Services DasigNEnginaedn) '~. t R Z I <br />Value ofApproved Donations <br />(Donated labor, matetlals and oquipmen[ <br />roved Pre-A regiment Costs <br />Real Pro rty Costs <br />Other <br />Other <br />Other <br />Other - ~ - - <br />Other <br /> <br /> <br /> <br /> <br /> <br />A: TOTAL PROJECT COSTS ZtZ t I L . (~ <br />B. Less Costs in Excess of Agreement <br />C. TOTAL ELIGIBLE COSTS - > ( S ~i , <br />ponsor a <br />(Mulllpry C by Required Match %} <br />2t ~ S ~ S <br />Z.- Q , S <br />IMB EME <br />(c minus o=E) - ~ <br />'3b 3`Ib,63 <br />6 '~t{G.b3 <br />Documentation Suanortln0 Exaendltures and Mafch wl!! be reaulred for every Reimbursement <br />1 certify that this billing is correct and is based on actual costs Incurred and can be supported with documentation on file with the sponsor. <br />I also certify that the work and services which have been performed to date are in accordance with Me approved project agreement including <br />amendments thereto; antl that Mis Sponsor has complied with al applicable State and local statutes. <br />I agree to retain recordapertaining to this billing far three yearspast the project completion tlate. <br />I ceNfy that this Sponsor; is not involved in any court litigation or lawsuit wherein it is alleged by private parties of the United Stales that person <br />were, on the grounds of race, color; or natural origin excluded from participation in, denietl benefits of, or otherwise subject to discriminaaon in <br />the programs or fa 'IJyies of this Spor/is r. <br />Signature: ~'l./~ ~ "~~~~ Date: y I ~~ 1 ~ ~ <br />Contact: ~C.iSC L4ry1 ° I~d6ti j Telephone# S ~ I ' 6 tsZ'~i8v3 <br />