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EVERETT <br /> WASHINGTON <br /> City of Everett Human Needs Grant <br /> January 1, 2021 through December 31, 2021 <br /> Exhibit C <br /> Request for Reimbursement <br /> Organization&Program: Domestic Violence Services:Children/Youth Program <br /> Mailing Address: P.O. Box 7,Everett,WA 98206-0007 <br /> Report Month and Year:Click or tap here to enter text. <br /> The expenditures made during the report month were for the specific purpose of: <br /> To provide comprehensive advocacy-based services for children/youth impacted by domestic violence <br /> Define one unit of service: Therapeutic Day Care—One hour child/parent service <br /> During this billing period a total of Click or tap here to enter text. units of service were provided to Click or tap here to enter <br /> t. residents of the City of Everett using these grant funds. <br /> Contact name/phone for questions on invoice: Click or tap here to enter text. <br /> Expenditures <br /> Category Total Budget Current Report Total Expenses Balance Remaining <br /> Period Billed to Date <br /> Salaries/Wages $ $ $ $ <br /> Benefits $ $ $ $ <br /> Office and Operating $ $ $ $ <br /> Supplies <br /> Professional Services $ $ $ $ <br /> Other: Click or tap here to entl $ <br /> $ $ $ <br /> Other: Click or tap here to er $ <br /> $ $ $ <br /> xt <br /> Total $19,776 $ $ $ <br /> Request for Payment: The undersigned Program Manager certifies that the information submitted in support of this Request for <br /> Reimbursement is true,accurate and complete to the best of their knowledge. <br /> Program Manager Signature Date <br /> Approved for Payment <br /> Kembra Landry Date <br /> Community Development Specialist <br /> GL Code: 009-5000199410 <br /> Vendor No: 02750 (City use only) <br /> 9 <br />