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7 <br /> Attachment C <br /> SNOHOMISH COUNTY <br /> HOUSING AND URBAN DEVELOPMENT PROJECTS <br /> REQUEST FOR REIMBURSEMENT/ACTUAL EXPENDITURE REPORT <br /> Date: <br /> Project Title: COMMUNITY HOUSING IMPROVEMENT PROGRAM HOME 2003#2 Object#0350 <br /> Contracting Qrganization/Agency: CITY OF EVERETT <br /> Report Period: V <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 <br /> above Contract Organization/Agency; <br /> 2. That the enclosed Report of Actual Expenditures and documentation accurately <br /> reflects materials furnished, services rendered, and/or labor performed in furtherance <br /> of the above project. <br /> 3. That payment has been made or is currently due or obligated for such materials, <br /> services and/or labor; <br /> 4. That such expenditures or current obligation constitute allowable costs under the <br /> principles in applicable Office of Management and Budget Circulars and conform to <br /> the approved Project Budget; and <br /> 5. That the materials, services, and/or labor for which reimbursement from HUD grant <br /> funds is requested by this document have not and will not be paid for or reimbursed <br /> by any other agency, corporation, partnership, firm or individual, OTHER THAN the <br /> Contracting Organization/Agency, its officers, agents, and/or employees. <br /> (Signature) <br /> (Typed Name) <br /> (Position) <br /> i8 <br />