Laserfiche WebLink
EXHIBIT F <br /> Request for Reimbursement/Actual Expenditure Report <br /> Date: Contract No.: <br /> Project Title: HopeWorks Station Residential <br /> Contracting Organization/Agency: HopeWorks Station Residential LLLP <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 /> Contracting 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; and <br /> 4. That the materials, services, and/or labor for which reimbursement from AHTF 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 /> Compliance <br /> ❑ Authorized Signature ❑ Within Budget <br /> ❑ Allowable/Eligible Cost ❑ Meets Contract Terms <br /> G.A. Date <br /> ❑ Sufficient Funds ❑ Documentation <br /> ❑ Allowable/Eligible Costs <br /> Financial Date <br /> Exhibit F <br /> City of Everett <br /> HopeWorks Station Residential LLLP <br /> Page 1 of 1 <br />