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9 <br /> Attachment E <br /> Request for Reimbursement/Actual Expenditure Report <br /> Date: Contract No.: ADDI 2003#2/ADDI 2004 #3/ <br /> ADDI 2005#2/ADDI 2006#1 <br /> Project Title: Everett ADDI Setaside <br /> Contracting Organization/Agency: City of Everett <br /> Amount of Claim: <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 <br /> Contracting Organization/Agency; <br /> 2. That the enclosed Report of Actual Expenditures and documentation accurately reflects <br /> materials furnished, services rendered, and/or labor performed in furtherance of the <br /> above project; <br /> 3. That payment has been made or is currently due or obligated for such materials, <br /> services and/or labor; and <br /> 4. That the materials, services, and/or labor for which reimbursement from ADDI funds is <br /> requested by this document have not and will not be paid for or reimbursed by any other <br /> agency, corporation, partnership, firm or individual, OTHER THAN the Contracting <br /> Organization/Agency, its officers, agents, and/or employees. <br /> (Signature) <br /> (Typed Name) <br /> (Position) <br /> Compliance <br /> ❑ Authorized Signature �.. �7 "Within udgb' ; <br /> [1Allowable/Eligible OKOANleets Contra4 <br /> r r te '" <br /> Terms <br /> GA; Date C5x: <br /> s y r .a} S XaFx.y 1 � �a rt la g?f T v t + °w ; •)' <br /> low ble/EligilileF• ,. <br /> xF s <br /> Financial a # <br /> ADDI Agreement between E - 1 <br /> City of Everett and Snohomish County <br />