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<br /> <br />EXHIBIT D <br /> <br />PROJECT REIMBURSMENT FORM <br />EVERETT GOSPEL MISSION PALLET PROJECT <br /> <br />Date: ______________ <br />Contact Name and Phone for Expenditures: _________________________________________ <br />Expenses Below were Incurred During (Time Period): _______________ to ________________ <br /> <br />CATEGORY BUDGET PERIOD <br />EXPENDITURE <br />PRIOR <br />EXPENDITURES TOTAL REMAINING <br />BUDGET <br />Salaries/Wages 184,820 <br />Benefits 50,046 <br />Supplies/Minor <br />Equip. 26,700 <br />Prof. Services 359,744 <br />Postage <br />Telephone <br />Mileage/Fares <br />Meals <br />Lodging <br />Advertising <br />Leases/Rentals <br />Insurance 12,000 <br />Utilities 31,344 <br />Repairs/Maint. 24,000 <br />Client Flex Funds 5,000 <br />Client Rent <br />Printing <br />Dues/Subscriptions <br />Regis/Tuition <br />Machinery/Equip <br />Administration 46,505 <br />Indirect <br />Occupancy <br />Misc. Construction <br />Acquisition <br />Relocation <br /> <br />TOTAL 740,159 <br />Request for Payment:The undersigned Designated Official certified that the information submitted <br />in support of this Request for Reimbursement is true, accurate and complete to the best of their <br />knowledge. <br /> <br />Approved for Payment (Signed): __________________________ Date: ________________ <br />Printed Name of Designated Official: ____________________________________________