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2022 CDBG Subrecipient Agreement <br /> Exhibit D <br /> EVERETT <br /> WASHINGTON <br /> COMMUNITY DEVELOPMENT BLOCK GRANT <br /> 2022 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 /> This form must match the project budget on file and be accompanied by backup documentation. <br /> Failure to do so may result in delay of reimbursement. Execution and delivery of this Contract Exhibit <br /> by the parties shall be legally valid and effective through any combination of: (i) executing and <br /> delivering a paper copy, (ii)transmitting the executed paper copy by email in pdf format or other <br /> electronically scanned format, or(iii) execution and transmittal by AdobeSign or DocuSign or similar e- <br /> signature method. <br /> Budget Category Budget Amount Current Period Total Expenses to Balance <br /> Expenditures Date Remaining <br /> _ $ <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 to: Vicki Dorway, Office of Community, Planning and Economic Development, <br /> 2930 Wetmore Avenue, Suite 8A, Everett, WA 98201 or vdorway@everettwa.gov <br />