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Attachment 3 to lnterlocal Agreement <br />INVOICE <br />(Request For Reimbursement / Actual Expenditure Report) <br />Date: ______________ _ Project Number: HCS-24-70-2402-198 <br />Project Title: City of Everett Emergency Bridge Housing Project <br />Contracting Organization/Agency: City of Everett/ Everett Gospel Mission <br />Report Period: ____________________________ _ <br />Draw#: <br />Amount of Request: __________________________ _ <br />CERTIFICATIONS: <br />I, the undersigned, do hereby certify under penalty of perjury: <br />1.That I am duly authorized to submit this claim for reimbursement on behalf of the above Contract <br />Organization/ Agency; <br />2.That the enclosed Report of Actual Expenditures and documentation accurately reflects materials <br />furnished, services rendered, and/or labor performed in furtherance of the above Project; <br />3.That payment has been made or is currently due or obligated for such materials, services and/or <br />labor; <br />4.That such expenditures or current obligation constitute allowable costs under the principles in <br />applicable Office of Management and Budget Circulars and conform to the approved Project Budget; <br />and <br />5.That the materials, services, and/or labor for which reimbursement from grant funds is requested by <br />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 />Compliance. <br />D A�thotizedSigriatiJ:te D · WjthinBl,ldget . □ AlloWll.ble}Eligible Cost D Meets Contract Tenns <br />□ Sufficient· funds D.Documentation <br />D Allo'N!lble/Eli�bl� Costs <br />Financial ___ Date ______ _ <br />(Signature) <br />(Name)