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<br /> <br />Exhibit C <br /> <br />Requisition for Payment <br />and Reporting Template <br /> <br /> <br />To: Puget Sound Regional Council <br />Attn: Accounts Payable <br />1011 Western Avenue, Suite 500 <br />Seattle, Washington 98104 <br />From: City of Everett <br />2930 Wetmore Ave <br />Everett, WA 98201 <br /> <br />Project Title: City of Everett Safe Streets and Roads for All (SS4A) Safety Action Plan <br />Project Agreement Number: 2023-10 <br /> <br /> <br />Invoice Period: From to . <br /> <br />Budget Table <br />Line Item Current Expense Total Expense <br />to Date Contract Budget <br />Personnel $ $ $ <br />Fringe Benefits $ $ $ <br />Travel $ $ $ <br />Equipment $ $ $ <br />Supplies $ $ $ <br />Contractual $ $ $ <br />Other $ $ $ <br />Total Direct Charges $ $ $ <br />Indirect Charges $ $ $ <br />Total Requisition this Period $ $ $ <br /> <br /> <br /> <br /> <br />I certify that the expenses listed above have been properly incurred in the accomplishment of the services <br />of this agreement. <br /> <br /> <br /> <br /> <br />Name, Title Date <br /> <br />