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EXHIBIT F <br /> REQUEST FOR REIMBURSEMENT/REPORT OF ACTUAL EXPENDITURES <br /> Date: <br /> Project Title: Everett— Community Housing Improvement Program <br /> Contract#: HCS-17-42-1701-198 <br /> Contracting Organization/Agency: City of Everett <br /> Report Period: <br /> Amount of Request: <br /> CERTFICATIONS: <br /> I, the undersigned, do hereby certify under penalty of perjury: <br /> 1. That I am duly authorized to submit this claim for reimbursement and report of <br /> actual expenditures on behalf of the above Agency; <br /> 2. That the enclosed Report of Actual Expenditures and documentation accurately <br /> reflects materials furnished, services rendered, and/or labor performed in <br /> furtherance 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; and <br /> 4. That the materials, services, and/or labor for which reimbursement from HOME <br /> funds is requested by this document have not and will not be paid for or <br /> reimbursed by any other agency, corporation, partnership, firm or individual, <br /> OTHER THAN the Agency, its officers, agents, and/or employees. <br /> Office Use Only: <br /> (Signature) <br /> Program <br /> FY (Typed Name) <br /> Obj# <br /> Date Posted (Position) <br /> % Complete <br /> CY <br /> Compliance <br /> C Authorized Signature [- Within Budget <br /> C. Allowable/Eligible Cost P Meets Contract Terms <br /> HSSII: Date Exhibit F <br /> HCS-17-42-1701-198 <br /> City of Everett <br /> Page 1 of 1 <br />