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EXHIBIT I <br /> CITY OF EVERETT <br /> HOUSING AND COMMUNITY DEVELOPMENT PROJECTS <br /> REQUEST FOR REIMBURSEMENT/ACTUAL EXPENDITURE REPORT <br /> Date: <br /> Project Title: COLBY AVENUE YOUTH CENTER <br /> Project Number: <br /> Contracting Organization/Agency: COCOON HOUSE <br /> Report Period: <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 above Contract <br /> 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 labor; <br /> 4. That such expenditures or current obligation constitute allowable costs under the principles in <br /> applicable Office of Management and Budget Circulars and conform to the approved Project Budget; <br /> and <br /> 5. That the materials, services, and/or labor for which reimbursement from HUD grant funds is requested <br /> by this document have not and will not be paid for or reimbursed by any other agency, corporation, <br /> partnership, firm or individual, OTHER THAN the Contracting Organization/Agency, its officers, agents, <br /> and/or employees. <br /> (Signature) <br /> Compliance <br /> ❑ Authorized Signature ❑ Within Budget (Typed Name) <br /> o Allowable/Eligible Cost 0 Meets Contract Terms <br /> G.A. Date <br /> O Sufficient Funds 0 Documentation (Position) <br /> O Allowable/Eligible Costs <br /> Financial Date <br /> IDIS#: <br /> Exhibit I <br /> Cocoon House <br /> Page 1 of 1 <br />