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11 <br /> 2020 CDBG Subrecipient Agreement E V E R E T T <br /> Exhibit D <br /> WASHINGTON <br /> City of Everett <br /> Community Development Block Grant <br /> 2020 Program Year Reimbursement Request <br /> Agency: <br /> Program: <br /> Mailing Address: <br /> The expenditures listed below were incurred during the following time period <br /> for the purpose of <br /> Contact name/phone for questions on expenditures: <br /> This form must match the project budget on file and be accompanied by backup documentation. Failure <br /> 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 />