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ism <br /> 2019 CDBG Subrecipient Agreement EVERETT <br /> Exhibit D <br /> WASHINGTON <br /> City of Everett <br /> Community Development Block Grant <br /> 2019 Program Year Reimbursement Request <br /> Agency: Dawson Place Child Advocacy Center <br /> Program: Bathroom Remodel <br /> Mailing Address: Dawson Place 1509 California Street Everett WA 98201 <br /> The expenditures listed below were incurred during the following time period <br /> None for the purpose of <br /> Contact name/phone for questions on expenditures: Lori Vanderburg 425 789-6200 <br /> THE CITY OF EVERETT CANNOT ACCEPT ELECTRONIC REIMBURSEMENTS. ALL REQUESTS FOR PAYMENT <br /> MUST HAVE ORIGINAL SIGNATURE.This form must match the project budget on file and be <br /> accompanied by source documentation. Failure to do so may result in delay of reimbursement. <br /> Category Budget Current Period Total Expenses to Balance <br /> Expenditures Date Remaining <br /> Request for Payment: The undersigned Program Manager certifies that the information submitted in <br /> support of this Request for Reimbursement is true,accurate and complete to the best of their <br /> knowledge. <br /> Approved for Payment: Date: <br /> Printed Name and Title of Program Manager: <br /> Please return this form, with original signature, to:Kembra Landry, Office of Community, Planning and <br /> Economic Development, 2930 Wetmore Avenue,Suite 8A, Everett, WA 98201 <br /> City Use Only: Vendor Number [ <br /> 2019 Grant Amount: [ ] <br />