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2021 CDBG Subrecipient Agreement Ems <br /> Exhibit D <br /> EVERETT <br /> WASHINGTON <br /> COMMUNITY DEVELOPMENT BLOCK GRANT <br /> 2021 PROGRAM YEAR REIMBURSEMENT REQUEST <br /> Date: <br /> Project Title: <br /> Subrecipient: <br /> Contact Name and Phone for expenditure questions: <br /> Expenditures listed below were incurred during the following time period: <br /> ALL REQUESTS FOR PAYMENT MUST SUBMIT DOCUMENTS WITH ORIGINAL SIGNATURE.This form must <br /> match the project budget on file and be accompanied by backup documentation. Failure to do so may <br /> result in delay of reimbursement. <br /> Budget Category Budget Amount Current Period Total Expenses to Balance <br /> Expenditures Date Remaining <br /> TOTAL $ - $ - $ - $ <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: Vicki Dorway, Office of Community, Planning and <br /> Economic Development, 2930 Wetmore Avenue, Suite 8A, Everett, WA 98201 <br /> City Use Only:Vendor Number [ ] <br /> 2021 Grant Amount: [ <br />