Laserfiche WebLink
Attachment E <br /> Request for Reimbursement/Actual Expenditure Report <br /> Date: _ Contract No.: HOME 2003#3; 2004#3 <br /> ADDI 2003 #1; 2004#1; 2005#3; 2006 #1 <br /> Project Title: HomeSight/City of Everett First Time Homebuyer Assistance <br /> Contracting Organization/Agency: HomeSight <br /> Total Amount of Claim: <br /> Total HOME Requested: Total ADDI Requested: <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 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; and <br /> 4. That the materials, services, and/or labor for which reimbursement from HOME funds is <br /> requested by this document have not and will not be paid for or reimbursed by any other agency, <br /> corporation, partnership, firm or individual, OTHER THAN the Contracting Organization/Agency, <br /> its officers, agents, and/or employees. <br /> (Signature) <br /> (Typed Name) <br /> (Position) <br /> Compliance <br /> Q Authorized Signature Q Within Budget <br /> E1 Allowable/Eligible Cost Cl Meets Contract <br /> Terns <br /> GAA, Date <br /> E] Sufficient Funds 0 Documentation <br /> II Allowable/Eligible Costs <br /> Financial Date <br /> E- 1 <br />