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3/24/2022 Landmark Web Official Records Search <br /> 202109300425 Document:COVENANTS Rec: S220.50 Page-14 of 18 <br /> Record Date:9/30/2021 12:45 PM Snohomish County,WA <br /> EXHIBIT I <br /> CITY OF EVERETT <br /> HOUSING AND COMMUNITY DEVELOPMENT PROJECTS <br /> REQUEST FOR REIMBURSEMENT/ACTUAL EXPENDITURE REPORT <br /> Date: <br /> Project Title: ASPENWOOL HABILITATION <br /> Project Number: , <br /> Contracting Organization/Agency: Uj.1G HOPE <br /> Report Period: on <br /> 0 <br /> Amount of Request: Or tt <br /> CEqTfo CATIONS: <br /> I,the undersigned,do hereby certify under penalty'pl p ury: <br /> 'iri9 <br /> 1. That I am duly authorized to submit this claim fnr reimbursement on behalf of the above Contract <br /> Organization/Agency; • <br /> 2. That the enclosed Report of Actual Expenditures an ti �ccumentation accurately reflects materials <br /> furnished,services rendered,and/or labor performed in\ tthiecance of the above project; <br /> 1 <br /> 3. That payment has been made or is currently due or obligatedouch materials,services and/or labor; <br /> iirl4. That such expenditures or current obligation constitute alio costs under the principles in <br /> applicable Office of Management and Budget Circulars and conf the approved Project Budget; <br /> and ' <br /> 5. That the materials,services,and/or labor for which reimbursement from HUD grant funds is requested <br /> by this document have not and will not be paid for or reimbursed by any other agency, corporation, <br /> partnership,firm or individual,OTHER THAN the Contracting Organization/Agency,its officers,agents, <br /> and/or employees. <br /> (Signature) <br /> ;Compliance_________-----.______------._.--_____ <br /> • ❑ Authorized Signature 0 Within Budget (Typed Name) <br /> ❑Allowable/Eligible Cost D Meets Contract Terris <br /> • <br /> G.A. Date <br /> 0 Sufficient Funds 0 Documentation (Position) <br /> 0 Allowable/Eligible Costs <br /> Financial Date <br /> IDIS#: Exhibit I <br /> Housing Hope <br /> . • Page 1 of 1 <br /> https://www.snoco.org/RecordedDocuments/search/index?theme=.blue&section=searchCriteriaParcelld&quickSearchSelection=# 14/18 <br />