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Contract #FY17-61017-004 <br /> Attachment 5 <br /> REPORT OF SERVICES <br /> Name of Project: Month: Year: <br /> Name of Person Performing Services: Describe the services you performed.(If you supervised others,include their names <br /> and positions.) <br /> Address: <br /> Telephone: <br /> How was the hourly rate shown below determined? <br /> Labor value appraisal on reverse side of this form. <br /> Did you receive any compensation for the time you <br /> devoted to this project? Other,explain: <br /> Yes ❑ No ❑ <br /> If yes,who paid you? <br /> How much were you paid? <br /> 0 <br /> Total number of hours worked each day duri4I this month: <br /> Beginning Sunday Monday Tuesday Wednesday Thursday Friday Saturday Totals <br /> I hereby swear that I devoted the time reported above,performing the Total hours this ii of hours <br /> work described on the project named. This time has not been reported month: <br /> for any other Federal or State project. <br /> Hourly rate: $ Per hour <br /> Date <br /> Amount charged to $ <br /> I supervised or coordinated this person's work and verify that it was project: <br /> performed as indicated above. <br /> Date <br /> INSTRUCTIONS: <br /> Washington State Office of Archaeology and Historic Preservation Use this form to document all labor,whether paid or <br /> 1110 S.Capitol Way,Suite 30 voluntary,which is claimed against a grant or used <br /> PO Box 48343 for the matching share of a grant. Complete it on a <br /> Olympia,WA 98504-8343 timely basis,i.e., fill it out immediately after the <br /> service is provided. <br /> 2003 Reprint <br />