HomeMy WebLinkAbout20133182.tiffReimbursement Request and Quarterly Project Progress Report Form
DOLA ENERGY and MINERAL IMPACT ASSISTANCE PROGRAM:
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WCR 49 Road Extension (Phase 1B)
Grantee & Project Name:
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licable Pur
Reimbursement Only
Reimbursement & Quarterly Report
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QUARTERLY EXPENDITURE SUMMARY
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ended in Quarter $
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Calendar Year 2012-13
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Pay Period Covered by this Request:
CURRENT REQUEST
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Amount to be
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PLEASE ENTER "X" IF THIS IS YOUR FINAL REQUEST:
Expense
Amount to be
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Impact Grant
and/or Loan
Funds
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Amount of Pay Request:
Total
Invoice
Amount
Date
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Invoice
Number
Date
eimbursement Request Number:1
EIAF
Contract Budget Line Item,
Name of Contractor, Vendor,
Professional Firm, etc.
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PROJECT EXPENSE SUMMARY (Total to Date)
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EIAF Reimbursement/Report
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Budgeted
Funds
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$1,825,000.00
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$250,000.001
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Total In -Kind
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Scope of
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EIAF
Contract Budget Expense
Item Description
(Per State Contract Scope of
Services)
Construction/Improvement of
Public Roadways
Arch/Engineering Services
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