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EXHIBIT D <br /> REQUEST FOR REIMBURSEMENT/REPORT OF ACTUAL EXPENDITURES <br /> Date: <br /> Project Title: Everett— Community Housing Improvement Program <br /> Contract#: HCS-19-42-1801-198 <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 actual <br /> 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 furtherance <br /> 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 funds <br /> is requested by this document have not and will not be paid for or reimbursed by any <br /> other agency, corporation, partnership, firm or individual, OTHER THAN the Agency, <br /> 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 /> Authorized Signature Within Budget <br /> Allowable/Eligible Cost ] Meets Contract Terms <br /> HSSII: Date <br /> Exhibit D <br /> HCS-19-42-1801-198 <br /> City of Everett <br /> Page 1 of 1 <br />