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Attachment F <br /> CITY OF EVERETT <br /> HOME PROJECTS <br /> REQUEST FOR REIMBURSEMENT/ACTUAL EXPENDITURE REPORT <br /> Date: <br /> Project Title: Silver Woods Apartments <br /> Contracting Organization/Agency: Senior Services of Snohomish County <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 /> Contract 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 above <br /> project. <br /> 3. That payment has been made or is currently due or obligated for such materials, services <br /> and/or labor; <br /> 4. That such expenditures or current obligation constitute allowable costs under the principles <br /> in applicable Office of Management and Budget Circulars and conform to the approved <br /> Project Budget; and <br /> 5. That the materials, services, and/or labor for which reimbursement from HUD grant 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 /> F - 1 <br />