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2022 HUD EDI Subrecipient Agreement <br />Exhibit D <br />Date: <br />Project Title: <br />Subrecipient: <br />Budget Category Budget Amount Current Period <br />Expenditures <br />Total Expenses to <br />Date <br />Balance <br />Remaining <br />-$ <br />-$ <br />-$ <br />-$ <br />-$ <br />-$ <br />-$ <br /> <br />TOTAL -$ -$ -$ -$ <br />Printed Name and Title of Program Manager: ______________________________________________ <br />Please return this form to: Kembra Landry, Office of Community, Planning and Economic Development, <br />2930 Wetmore Avenue, Suite 8A, Everett, WA 98201 or klandry@everettwa.gov <br />ECONOMIC DEVELOPMENT INITIATIVE <br />2022 PROGRAM YEAR REIMBURSEMENT REQUEST <br />FAITH FAMILY VILLAGE <br />INTERFAITH ASSOCIATION OF NORTHWEST WASHINGTON <br />Contact Name and Phone for expenditure questions:_______________________________________ <br />Expenditures listed below were incurred during the following time period:_____________________ <br />Approved for Payment:____________________________________Date:_________________________ <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 />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.