HomeMy WebLinkAbout20091340.tiffRESOLUTION
RE: APPROVE CONTRACT AMENDMENT FOR 2009-2010 COMMUNITY SERVICES BLOCK
GRANT AND AUTHORIZE CHAIR TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with a Contract Amendment for the 2009-2010
Community Services Block Grant between the County of Weld, State of Colorado, by and through
the Board of County Commissioners of Weld County, on behalf of the Department of Human
Services, and the Colorado Department of Local Affairs, commencing March 1, 2009, and ending
February 28, 2010, with further terms and conditions being as stated in said amendment, and
WHEREAS, after review, the Board deems it advisable to approve said amendment, a copy
of which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the Contract Amendment for 2009-2010 Community Services Block Grant
between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Department of Human Services, and the Colorado
Department of Local Affairs be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said amendment.
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 15th day of June, A.D., 2009, nunc pro tunc March 1, 2009.
ATTEST:
Weld County Clerk to the Bo
BY
Dep
APP
afri
o the Board
RM:
nt
Attorney
y
Date of signature
(0I9&loci
BOARD OF COUNTY COMMISSIONERS
ELD COUN'%�OLORADO
2
iam F. Garcia, Chair
Sean P% onway
BarKirkmeye
Ceti (Cm
David E. Long
2009-1340
HR0080 C� �� 7
MEMORANDUM
DATE: June 11, 2009
ITO: William F. Garcia, Chair, Board of County Commiss.}o s
WILD O nj
FROM: Judy A. Griego, Director, Human SerJicG�D��ine'ut"
COLORADO RE: Amendment to the Community Services Block Grant for PY
2009-2010 between the Weld County Department of Human
Services and the Colorado Department of Local Affairs
Enclosed for Board approval is the Amendment to the Community Services Block Grant for
Program Year 2009-2010 between the Weld County Department of Human Services and the
Colorado Department of Local Affairs. This Grant Amendment was presented at the Board's
June 8, 2009, Work Session.
This Amendment increases the dollar amount of funding for the current CSBG contract for
2009-2010 by $20,000.00. These funds must be spent by February 28, 2010.
The focus of the Grant is linkages of services and providing general assistance and transportation
for the low-income citizens of Weld County.
The term of this Grant is March 1, 2009 through February 28, 2010.
If you have any questions, give me a call at extension 6510.
2009-1340
CSBG #44
CONTRACT AMENDMENT
Amendment #: 1
Encumbrance #: L9CSBG44
Original Contract CLIN #: 09-1091
Amendment CLIN #: -7...$ S
1)
PARTIES
This Amendment to the above -referenced Original Contract (hereinafter called the Contract) is entered into by
and between Weld County (hereinafter called "Contractor"), and the STATE OF COLORADO (hereinafter
called the "State") acting by and through the Department of Local Affairs, (hereinafter called "DOLA").
2) EFFECTIVE DATE AND ENFORCEABILITY
This Amendment shall not be effective or enforceable until it is approved and signed by the Colorado State
Controller or designee (hereinafter called the "Effective Date"). The State shall not be liable to pay or
reimburse Contractor for any performance hereunder including, but not limited to, costs or expenses incurred,
or be bound by any provision hereof prior to the Effective Date.
3) FACTUAL RECITALS
The Parties entered into the Contract for CSBG funds in Weld County will provide services to the low-income
citizens of the County through partnerships between Weld County Department of Human Services and
WELDCO.
4) CONSIDERATION -COLORADO SPECIAL PROVISIONS
The Parties acknowledge that the mutual promises and covenants contained herein and other good and
valuable consideration are sufficient and adequate to support this Amendment. The Parties agree to replacing
the Colorado Special Provisions with the most recent version (if such have been updated since the Contract
and any modification thereto were effective) as part consideration for this Amendment.
5) LIMITS OF EFFECT
This Amendment is incorporated by reference into the Contract, and the Contract and all prior amendments
thereto, if any, remain in full force and effect except as specifically modified herein.
6) MODIFICATIONS
The Amendment and all prior amendments thereto, if any, are modified as follows:
a. Payments to Grantee: #9 A. Maximum Amount: in the Original Contract is modified by deleting "TWO
HUNDRED EIGHTY THOUSAND TWO HUNDRED FOURTEEN AND XX/100 Dollars ( $280,214 )" and
inserting in lieu there of "THREE HUNDRED THOUSAND THREE HUNDRED EIGHTY-EIGHT AND
XX/100 Dollars ( $300,388 )."
b. Statement of Project: #6 Project Budget: is modified by deleting the current Budget and inserting new
Budget.
"Project Activities
Payments made in accordance with eligible expenses as
outlined in §1 of this Exhibit. No other expenses are eligible.
TOTAL
Total Project Costs
$300,388
$300,388
7) START DATE
This Amendment shall take effect on the later of its Effective Date or March 1, 2009.
8) ORDER OF PRECEDENCE
Except for the Special Provisions, in the event of any conflict, inconsistency, variance, or contradiction
between the provisions of this Amendment and any of the provisions of the Contract, the provisions of this
Amendment shall in all respects supersede, govern, and control. The most recent version of the Special
Provisions incorporated into the Contract or any amendment shall always control other provisions in the
Contract or any amendments.
9) AVAILABLE FUNDS
Financial obligations of the state payable after the current fiscal year are contingent upon funds for that
purpose being appropriated, budgeted, or otherwise made available.
Page 1 of 2
Form Revised: 11/20/08
dcoQ-13/4
CSBG #44
THE PARTIES HERETO HAVE EXECUTED THIS AMENDMENT
* Persons signing for Contractor hereby swear and affirm that they are authorized to act on Contractor's
behalf and acknowledge that the State is relying on their representations to that effect.
CONTRACTOR
Weld County
By: William F. Garcia
STATE OF COLORADO
Bill Ritter, Jr. GOVERNOR
Department of Lo al
Affairs
Name of Authorized Individual
✓ JI By:
Title: Chair, Board of County Commi ssi oners
Sus E. irkpatrick,
cutive Director
OfficialTitle of A ized Individual
Date: I / it n
C� 1
f/
ignature
Date: JUN 1 5 2009
PRE -APPROVED FORM
By:
CONTRACT REVIEWER
Luci Smead, Fe eral Grants Program Manager
Date: /0// l9/ O,
ALL CONTRACTS REQUIRE APPROVAL BY THE STATE CONTROLLER
CRS §24-30-202 requires the State Controller to approve all State Contracts. This Contract is not valid until
signed and dated below by the State Controller or delegate. Contractor is not authorized to begin
performance until such time. If Contractor begins performing prior thereto, the State of Colorado is not
obligated to pay Contractor for such performance or for any goods and/or services provided hereunder,
STATE
Davyd
/v(���
CONTROLLER
J. McDermot
A
By:
-‘)T-Ice kfario 41r, Controller Dele ate
Date: 10/(q
Page 2 of 2
�Il Form Revised: 11/20/08
&oo9-/3`/O
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IVIItD'“.V11A•II,
10 COLORADO
www.coiorado.gov/census2010
What: The census is a count of everyone residing in the
United States.
Who: All U.S. residents must be counted — people of all
races and ethnic groups, both citizens and non -citizens.
When: Census Day is April 1, 2010. Questionnaire
responses should represent the household as it exists on
this day. More detailed socioeconomic information will be
collected annually from a small percentage of the population
through the American Community Survey.
Why the Census Matters — Money
Approximately $300 billion in federal dollars are distributed annually based
on census results. This represents approximately $826 per person each
year. In order to ensure that Coloradans get their fair share of these
resources for schools, roads, daycare centers, medical facilities and the
like, the full participation of all Coloradans in Census 2010 must be
encouraged. The more aware residents are of the 2010 Census, they are
i, more willing to participate in a successful enumeration.
Census data may be used to guide important decisions for communities,
such as where to build roads, schools, job training centers and more.
I Billions of dollars in funds for these projects are at stake — an incomplete
l count could mean your community misses out.
Why the Census Matters — Power
The decennial census is used not only used to apportion seats in the U.S.
House of Representatives, but census data are used to define legislative
districts, school districts, and other local areas of government.
Why the Census Matters — Intelligence
Census data are used to inform your community's decisions. It is like a
snapshot that helps define who you are as a community. Data about
changes in your community are crucial to many planning decisions,
such as:
v where to provide services for the elderly
• where to build new roads and schools
• where to locate job training centers, community centers and
• other service facilities
bias been a C tts?
eau liaison since 1 81ff
'Asti*
a q I
kcal governmEints
iv3 tots census progr'
a�tart of the Go f `
lete Count ;of,
s sor a Colorado C
s a'vommunity leader,,
ou:tan raise awarene
of and encourage
ipation in this
Mato! c event. " With:onl'
Otiestions, the 2010
ens +s'questionnaite ia'
ne of the shortest
questionnaires in histo`
rand takes just 10 mina ..
o complete.
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10 Census: PARTNERSHIP AT A GLANCE
10 COLORADO
www. colora do. gov/censu s2010
Your partnership sends a strong message to your community about the importance of the census and the
benefits of being counted. Please feel free to contact our office (3O3) 866-4147 if you have any
questions.
Start a Complete Count Committee (CCC). A Complete Count Committee is a volunteer committee
established to increase awareness about the census and to motivate residents in the community to
respond with the result of the best, most accurate, count in Colorado.
URPOSE
✓ Inform: What is the Census? Why is it Important? Where can you find more information?
How confidential is the information? What is the Census Schedule?
• Identify: "hard -to -count areas" and areas of concern.
• Focus: resources on hard -to -count populations
• Encourage: local leaders and decision makers to support and publicize Census 2010 activities.
• Assist direct clients: employees with extensive public contact can encourage and assist
clients in completing and returning census forms.
• Encourage: persons to complete and return 2010 Census questionnaires.
'ossible Activities for a Complete Count Committee Member:
1. Create a 2010 website or link to ours www.colorado.gov/census2010
2. Print census messages on state products, envelopes bulletins, posters, exhibits and newsletters
3. Recruitment assistance
4. ID hard to count populations and barriers to a successful Census 2010
5. Develop strategies for targeting hard -to -count populations and barriers
6. Develop information on federally funded programs tied to census data
7. Include 2010 Census on agendas of meetings and agency sponsored events
8. Display 2010 Census material in public buildings
9. Include census message on mailings
10. Include census message on paystubs
Fall 2008
Spring 2009
Recruitment begins for local census jobs for early census operations
Census employees go door-to-door to update address lists nationwide
Fall 2009
February —March 2010
Recruitment begins for census takers to support peak workload in 2010
Census questionnaires are mailed or delivered to households
April 1, 2010
May —July 2010
Census Day
Census takers visit households that did not return a questionnaire by mail
December 2010
March 2011
By law, Census Bureau delivers population counts to the president for apportionment
By law, Census Bureau completes delivery of redistricting data to states
Ova psnd, c
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For more information about the 2010 Census, go to www.colorado.gov/census2010
STATE OF COLORADO
DEPARTMENT OF LOCAL AFFAIRS
1313 Sherman Street, Suite 521
Denver, Colorado 80203
Phone: (303) 866-2771
FAX: (303) 866-4819
TDD: (303) 866-5300
MEMORANDUM
TO: CSBG ELIGIBLE GRANTEES
u�
FROM: Lucia Smead, Federal Grants PGm pager
Christy Culp, Community Development Specialis
DATE: August 2009
RE: CSBG ARRA Contract
Bill Ritter, Ir.
Governor
Susan E. Kirkpatrick
Executive Director
Enclosed is the fully executed contract for the CSBG ARRA program. The contract start date is
July 1, 2009 and ends September 30, 2011.
Carefully review the Statement of Project to verify how the ARRA grant funds will be spent for
your entity. When submitting reimbursement requests all appropriate backup documentation
identified in the Statement of Project must accompany the request.
We would like to caution you to make sure that you keep the regular CSBG and the CSBG
ARRA program separate. Included with this information are monthly reimbursement request
forms and quarterly report forms, printed on colored paper. The payment request and quarterly
reports must be submitted using the colored paper reports. This will assure everyone that the
correct grant dollars are being used appropriately and in the allotted timeframe.
In addition, a calendar of deadlines and the CSBG ARRA poverty guideline are included with
this packet of information.
There will be updates consistently during the ARRA program grant cycle and we will make every
effort to update you as we receive the information. Most training will occur using the webinar
format. We will notify you via email and will count on each entity to provide the information to
any subgrantees to participate in appropriate trainings.
We look forward to working together during this current grant cycle.
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STATE OF COLORADO
Department of Local Affairs
COMMUNITY SERVICES BLOCK GRANT RECOVERY ACT
QUARTERLY PROGRAM REPORT
Name of Grantee:
Contract Encumbrance No: L10CSBG R
Name/Title of Project:
Reporting Period:
_July 1 through September 30, 2009 Due October 5 2009
October 1 through December 31, 2009 Due January 5, 2010
_January 1 through March 31, 2010 Due April 5, 2010
April 1 through June 30, 2010 Due July 5, 2010
_July 1 through September 30, 2010 Due October 5, 2010
What has been undertaken and/or completed during the CURRENT reporting period? How does this
progress relate to "outcomes" contained in the approved RFP?
2. What will be undertaken and/or completed during the NEXT reporting period? How does this projected
progress relate to the "outcomes" contained in the approved RFP?
QUARTERLY PROGRAM REPORT
3. Have any complaints been received or have problems or issues developed related to financial
management, program implementation, client outreach or other matters? If so, how have these
complaints been resolved?
4. What, if any, additional technical assistance is needed to successfully complete the projects?
5. Document number of clients served and current progress of clients, i.e. number enrolled in job related
programs, number obtained jobs, number still in jobs, number that have become self-sufficient.
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10. TOTAL
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DATE REPORT SUBMITTED:
PHONE #: ( )
EMAIL ADDRESS:
9. Health
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SIGNATURE OF AUTHORIZED OFFICIAL:
NAME AND TITLE: (Print or Type)
6. Nutrition
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REPORTING AGENCY: (Name and Address)
PERIOD COVERED BY THIS REPORT:
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MAIL TO: DEPARTMENT OF LOCAL AFFAIRS
1313 Sherman Street, #521
Denver, CO 80203
ATTN: Lucia Smead
PROGRAM PERIOD:
From: To:
(MO/DAY/YR) (MO/DAY/YR)
certdlcation:
I certify to the best of my knowledge and belief
the data above is correct and that all expenditures were
made in accordance with the grant agreement.
1. Employment
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Expenditure
Categories
a. Net expenditures
previously reported
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(line a+b)
d. Total CSBG funds
*place dollar
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e. Unobligated balance
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9. Health
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Certification: SIGNATURE OF AUTHORIZED OFFICIAL:
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1. Employment
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CSBG RECOVERTY ACT
MONTHLY
DUE THE 20TH OF EACH MONTH
REQUEST FOR REIMBURSEMENT REPORT
Copies of backup information (receipts, invoices, signed timesheets, etc.) must be
provided with the Reimbursement Report. The backup information must equal the
amount being requested, detailed in the Statement of Project (SOP), and be within the
timeframe of the contract.
MAIL TO:
CSBG
DOLA - DLGS
1313 Sherman Street - Room 521
Denver, CO 80203
ATTN: Lucia Smead
TYPE OF PAYMENT:
— Reimbursement
— Final
REPORTING AGENCY:
(Name and Remit Address)
PERIOD COVERED BY THIS REQUEST:
From: To:
PAYMENT REQUEST NUMBER:
#
CONTRACT ENCUMBRANCE
NUMBER:
L10CSBG R
(Mo/Day/Yr) (Mo/Day/Yr)
COMPUTATION OF AMOUNT of REIMBURSEMENT REQUESTED
a. Actual Cumulative Funds Expended
$
b. Total Funds Previously Received
$
c. Amount of this cash request
$
CERTIFICATION:
I certify to the best of my knowledge and belief the
data above is correct and that all expenditures were
made in accordance with grant agreements.
SIGNATURE OF
AUTHORIZED OFFICIAL:
DATE REPORT SUBMITTED:
NAME AND TITLE:
(Type or Print)
PHONE #:
( )
EMAIL ADDRESS:
CSBG RECOVERTY ACT
MONTHLY
DUE THE 20TH OF EACH MONTH
REQUEST FOR REIMBURSEMENT REPORT
Copies of backup information (receipts, invoices, signed timesheets, etc.) must be
provided with the Reimbursement Report. The backup information must equal the
amount being requested, detailed in the Statement of Project (SOP), and be within the
timeframe of the contract.
MAIL TO:
CSBG
DOLA - DLGS
1313 Sherman Street - Room 521
Denver, CO 80203
ATTN: Lucia Smead
TYPE OF PAYMENT:
— Reimbursement
Final
REPORTING AGENCY:
(Name and Remit Address)
PERIOD COVERED BY THIS REQUEST:
From: To:
PAYMENT REQUEST NUMBER:
#
CONTRACT ENCUMBRANCE
NUMBER:
L10CSBG R
(Mo/Day/Yr) (Mo/Day/Yr)
COMPUTATION OF AMOUNT of REIMBURSEMENT REQUESTED
a. Actual Cumulative Funds Expended
$
b. Total Funds Previously Received
$
c. Amount of this cash request
$
CERTIFICATION:
I certify to the best of my knowledge and belief the
data above is correct and that all expenditures were
made in accordance with grant agreements.
SIGNATURE OF
AUTHORIZED OFFICIAL:
DATE REPORT SUBMITTED:
NAME AND TITLE:
(Type or Print)
PHONE #:
( )
EMAIL ADDRESS:
CSBG RECOVERTY ACT
MONTHLY
DUE THE 20TH OF EACH MONTH
REQUEST FOR REIMBURSEMENT REPORT
Copies of backup information (receipts, invoices, signed timesheets, etc.) must be
provided with the Reimbursement Report. The backup information must equal the
amount being requested, detailed in the Statement of Project (SOP), and be within the
timeframe of the contract.
MAIL TO:
CSBG
DOLA - DLGS
1313 Sherman Street - Room 521
Denver, CO 80203
ATTN: Lucia Smead
TYPE OF PAYMENT:
— Reimbursement
— Final
REPORTING AGENCY:
(Name and Remit Address)
PERIOD COVERED BY THIS REQUEST:
From: To:
PAYMENT REQUEST NUMBER:
#
CONTRACT ENCUMBRANCE
NUMBER:
L10CSBG R
(Mo/Day/Yr) (Mo/Day/Yr)
COMPUTATION OF AMOUNT of REIMBURSEMENT REQUESTED
a. Actual Cumulative Funds Expended
$
b. Total Funds Previously Received
$
c. Amount of this cash request
$
CERTIFICATION:
I certify to the best of my knowledge and belief the
data above is correct and that all expenditures were
made in accordance with grant agreements.
SIGNATURE OF
AUTHORIZED OFFICIAL:
DATE REPORT SUBMITTED:
NAME AND TITLE:
(Type or Print)
PHONE #:
( )
EMAIL ADDRESS:
CSBG RECOVERTY ACT
MONTHLY
DUE THE 20TH OF EACH MONTH
REQUEST FOR REIMBURSEMENT REPORT
Copies of backup information (receipts, invoices, signed timesheets, etc.) must be
provided with the Reimbursement Report. The backup information must equal the
amount being requested, detailed in the Statement of Project (SOP), and be within the
timeframe of the contract.
MAIL TO:
CSBG
DOLA - DLGS
1313 Sherman Street - Room 521
Denver, CO 80203
ATTN: Lucia Smead
TYPE OF PAYMENT:
Reimbursement
_ Final
REPORTING AGENCY:
(Name and Remit Address)
PERIOD COVERED BY THIS REQUEST:
From: To:
PAYMENT REQUEST NUMBER:
#
CONTRACT ENCUMBRANCE
NUMBER:
L10CSBG R
(Mo/Day/Yr) (Mo/Day/Yr)
COMPUTATION OF AMOUNT of REIMBURSEMENT REQUESTED
a. Actual Cumulative Funds Expended
$
b. Total Funds Previously Received
$
c. Amount of this cash request
$
CERTIFICATION:
I certify to the best of my knowledge and belief the
data above is correct and that all expenditures were
made in accordance with grant agreements.
SIGNATURE OF
AUTHORIZED OFFICIAL:
DATE REPORT SUBMITTED:
NAME AND TITLE:
(Type or Print)
PHONE #:
( )
EMAIL ADDRESS:
CSBG RECOVERTY ACT
MONTHLY
DUE THE 20TH OF EACH MONTH
REQUEST FOR REIMBURSEMENT REPORT
Copies of backup information (receipts, invoices, signed timesheets, etc.) must be
provided with the Reimbursement Report. The backup information must equal the
amount being requested, detailed in the Statement of Project (SOP), and be within the
timeframe of the contract.
MAIL TO:
CSBG
DOLA - DLGS
1313 Sherman Street - Room 521
Denver, CO 80203
ATTN: Lucia Smead
TYPE OF PAYMENT:
—Reimbursement
Final
REPORTING AGENCY:
(Name and Remit Address)
PERIOD COVERED BY THIS REQUEST:
From: To:
PAYMENT REQUEST NUMBER:
#
CONTRACT ENCUMBRANCE
NUMBER:
L1 OCSBG R
(Mo/Day/Yr) (Mo/Day/Yr)
COMPUTATION OF AMOUNT of REIMBURSEMENT REQUESTED
a. Actual Cumulative Funds Expended
$
b. Total Funds Previously Received
$
c. Amount of this cash request
$
CERTIFICATION:
I certify to the best of my knowledge and belief the
data above is correct and that all expenditures were
made in accordance with grant agreements.
SIGNATURE OF
AUTHORIZED OFFICIAL:
DATE REPORT SUBMITTED:
NAME AND TITLE:
(Type or Print)
PHONE #:
( )
EMAIL ADDRESS:
CSBG RECOVERTY ACT
MONTHLY
DUE THE 20TH OF EACH MONTH
REQUEST FOR REIMBURSEMENT REPORT
Copies of backup information (receipts, invoices, signed timesheets, etc.) must be
provided with the Reimbursement Report. The backup information must equal the
amount being requested, detailed in the Statement of Project (SOP), and be within the
timeframe of the contract.
MAIL TO:
CSBG
DOLA - DLGS
1313 Sherman Street - Room 521
Denver, CO 80203
ATTN: Lucia Smead
TYPE OF PAYMENT:
— Reimbursement
— Final
REPORTING AGENCY:
(Name and Remit Address)
PERIOD COVERED BY THIS REQUEST:
From: To:
PAYMENT REQUEST NUMBER:
#
CONTRACT ENCUMBRANCE
NUMBER:
L10CSBG R
(Mo/Day/Yr) (Mo/Day/Yr)
COMPUTATION OF AMOUNT of REIMBURSEMENT REQUESTED
a. Actual Cumulative Funds Expended
$
b. Total Funds Previously Received
$
c. Amount of this cash request
$
CERTIFICATION:
I certify to the best of my knowledge and belief the
data above is correct and that all expenditures were
made in accordance with grant agreements.
SIGNATURE OF
AUTHORIZED OFFICIAL:
DATE REPORT SUBMITTED:
NAME AND TITLE:
(Type or Print)
PHONE #:
( )
EMAIL ADDRESS:
CSBG RECOVERTY ACT
MONTHLY
DUE THE2Om OF EACH MONTH
REQUEST FOR REIMBURSEMENT REPORT
Copies of backup information (receipts, invoices, signed timesheets, etc.) must be
provided with the Reimbursement Report. The backup information must equal the
amount being requested, detailed in the Statement of Project (SOP), and be within the
timeframe of the contract.
MAIL TO:
CSBG
DOLA - DLGS
1313 Sherman Street - Room 521
Denver, CO 80203
ATTN: Lucia Smead
TYPE OF PAYMENT:
— Reimbursement
— Final
REPORTING AGENCY:
(Name and Remit Address)
PERIOD COVERED BY THIS REQUEST:
From: To:
PAYMENT REQUEST NUMBER:
#
CONTRACT ENCUMBRANCE
NUMBER:
L10CSBG R
(Mo/Day/Yr) (Mo/Day/Yr)
COMPUTATION OF AMOUNT of REIMBURSEMENT REQUESTED
a. Actual Cumulative Funds Expended
$
b. Total Funds Previously Received
$
c. Amount of this cash request
$
CERTIFICATION:
I certify to the best of my knowledge and belief the
data above is correct and that all expenditures were
made in accordance with grant agreements.
SIGNATURE OF
AUTHORIZED OFFICIAL:
DATE REPORT SUBMITTED:
NAME AND TITLE:
(Type or Print)
PHONE #:
( )
EMAIL ADDRESS:
CSBG RECOVERTY ACT
MONTHLY
DUE THE 20TH OF EACH MONTH
REQUEST FOR REIMBURSEMENT REPORT
Copies of backup information (receipts, invoices, signed timesheets, etc.) must be
provided with the Reimbursement Report. The backup information must equal the
amount being requested, detailed in the Statement of Project (SOP), and be within the
timeframe of the contract.
MAIL TO:
CSBG
DOLA - DLGS
1313 Sherman Street - Room 521
Denver, CO 80203
ATTN: Lucia Smead
TYPE OF PAYMENT:
— Reimbursement
_ Final
REPORTING AGENCY:
(Name and Remit Address)
PERIOD COVERED BY THIS REQUEST:
From: To:
PAYMENT REQUEST NUMBER:
#
CONTRACT ENCUMBRANCE
NUMBER:
L1 OCSBG R
(Mo/Day/Yr) (Mo/Day/Yr)
COMPUTATION OF AMOUNT of REIMBURSEMENT REQUESTED
a. Actual Cumulative Funds Expended
$
b. Total Funds Previously Received
$
c. Amount of this cash request
$
CERTIFICATION:
I certify to the best of my knowledge and belief the
data above is correct and that all expenditures were
made in accordance with grant agreements.
SIGNATURE OF
AUTHORIZED OFFICIAL:
DATE REPORT SUBMITTED:
NAME AND TITLE:
(Type or Print)
PHONE #:
( )
EMAIL ADDRESS:
CSBG RECOVERTY ACT
MONTHLY
DUE THE 20TH OF EACH MONTH
REQUEST FOR REIMBURSEMENT REPORT
Copies of backup information (receipts, invoices, signed timesheets, etc.) must be
provided with the Reimbursement Report. The backup information must equal the
amount being requested, detailed in the Statement of Project (SOP), and be within the
timeframe of the contract.
MAIL TO:
CSBG
DOLA - DLGS
1313 Sherman Street - Room 521
Denver, CO 80203
ATTN: Lucia Smead
TYPE OF PAYMENT:
— Reimbursement
_ Final
REPORTING AGENCY:
(Name and Remit Address)
PERIOD COVERED BY THIS REQUEST:
From: To:
PAYMENT REQUEST NUMBER:
#
CONTRACT ENCUMBRANCE
NUMBER:
L1 OCSBG R
(Mo/Day/Yr) (Mo/Day/Yr)
COMPUTATION OF AMOUNT of REIMBURSEMENT REQUESTED
a. Actual Cumulative Funds Expended
b. Total Funds Previously Received
$
c. Amount of this cash request
$
CERTIFICATION:
I certify to the best of my knowledge and belief the
data above is correct and that all expenditures were
made in accordance with grant agreements.
SIGNATURE OF
AUTHORIZED OFFICIAL:
DATE REPORT SUBMITTED:
NAME AND TITLE:
(Type or Print)
PHONE #:
( )
EMAIL ADDRESS:
CSBG RECOVERTY ACT
MONTHLY
DUE THE20TH OF EACH MONTH
REQUEST FOR REIMBURSEMENT REPORT
Copies of backup information (receipts, invoices, signed timesheets, etc.) must be
provided with the Reimbursement Report. The backup information must equal the
amount being requested, detailed in the Statement of Project (SOP), and be within the
timeframe of the contract.
MAIL TO:
CSBG
DOLA - DLGS
1313 Sherman Street - Room 521
Denver, CO 80203
ATTN: Lucia Smead
TYPE OF PAYMENT:
— Reimbursement
_ Final
REPORTING AGENCY:
(Name and Remit Address)
PERIOD COVERED BY THIS REQUEST:
From: To:
PAYMENT REQUEST NUMBER:
#
CONTRACT ENCUMBRANCE
NUMBER:
L10CSBG R
(Mo/Day/Yr) (Mo/Day/Yr)
COMPUTATION OF AMOUNT of REIMBURSEMENT REQUESTED
a. Actual Cumulative Funds Expended
$
b. Total Funds Previously Received
$
c. Amount of this cash request
$
CERTIFICATION:
I certify to the best of my knowledge and belief the
data above is correct and that all expenditures were
made in accordance with grant agreements.
SIGNATURE OF
AUTHORIZED OFFICIAL:
DATE REPORT SUBMITTED:
NAME AND TITLE:
(Type or Print)
PHONE #:
( )
EMAIL ADDRESS:
CSBG RECOVERTY ACT
MONTHLY
DUE THE2OTH OF EACH MONTH
REQUEST FOR REIMBURSEMENT REPORT
Copies of backup information (receipts, invoices, signed timesheets, etc.) must be
provided with the Reimbursement Report. The backup information must equal the
amount being requested, detailed in the Statement of Project (SOP), and be within the
timeframe of the contract.
MAIL TO:
CSBG
DOLA - DLGS
1313 Sherman Street - Room 521
Denver, CO 80203
ATTN: Lucia Smead
TYPE OF PAYMENT:
— Reimbursement
— Final
REPORTING AGENCY:
(Name and Remit Address)
PERIOD COVERED BY THIS REQUEST:
From: To:
PAYMENT REQUEST NUMBER:
#
CONTRACT ENCUMBRANCE
NUMBER:
L1 OCSBG R
(Mo/Day/Yr) (Mo/Day/Yr)
COMPUTATION OF AMOUNT of REIMBURSEMENT REQUESTED
a. Actual Cumulative Funds Expended
$
b. Total Funds Previously Received
$
c. Amount of this cash request
$
CERTIFICATION:
I certify to the best of my knowledge and belief the
data above is correct and that all expenditures were
made in accordance with grant agreements.
SIGNATURE OF
AUTHORIZED OFFICIAL:
DATE REPORT SUBMITTED:
NAME AND TITLE:
(Type or Print)
PHONE #:
( )
EMAIL ADDRESS:
CSBG RECOVERTY ACT
MONTHLY
DUE THE 20TH OF EACH MONTH
REQUEST FOR REIMBURSEMENT REPORT
Copies of backup information (receipts, invoices, signed timesheets, etc.) must be
provided with the Reimbursement Report. The backup information must equal the
amount being requested, detailed in the Statement of Project (SOP), and be within the
timeframe of the contract.
MAIL TO:
CSBG
DOLA - DLGS
1313 Sherman Street - Room 521
Denver, CO 80203
ATTN: Lucia Smead
TYPE OF PAYMENT:
— Reimbursement
Final
REPORTING AGENCY:
(Name and Remit Address)
PERIOD COVERED BY THIS REQUEST:
From: To:
PAYMENT REQUEST NUMBER:
#
CONTRACT ENCUMBRANCE
NUMBER:
L10CSBG R
(Mo/Day/Yr) (Mo/Day/Yr)
COMPUTATION OF AMOUNT of REIMBURSEMENT REQUESTED
a. Actual Cumulative Funds Expended
$
b. Total Funds Previously Received
$
c. Amount of this cash request
$
CERTIFICATION:
I certify to the best of my knowledge and belief the
data above is correct and that all expenditures were
made in accordance with grant agreements.
SIGNATURE OF
AUTHORIZED OFFICIAL:
DATE REPORT SUBMITTED:
NAME AND TITLE:
(Type or Print)
PHONE #:
( )
EMAIL ADDRESS:
CSBG RECOVERTY ACT
MONTHLY
DUE THE 20TH OF EACH MONTH
REQUEST FOR REIMBURSEMENT REPORT
Copies of backup information (receipts, invoices, signed timesheets, etc.) must be
provided with the Reimbursement Report. The backup information must equal the
amount being requested, detailed in the Statement of Project (SOP), and be within the
timeframe of the contract.
MAIL TO:
CSBG
DOLA - DLGS
1313 Sherman Street - Room 521
Denver, CO 80203
ATTN: Lucia Smead
TYPE OF PAYMENT:
— Reimbursement
Final
REPORTING AGENCY:
(Name and Remit Address)
PERIOD COVERED BY THIS REQUEST:
From: To:
PAYMENT REQUEST NUMBER:
#
CONTRACT ENCUMBRANCE
NUMBER:
L10CSBG R
(Mo/Day/Yr) (Mo/Day/Yr)
COMPUTATION OF AMOUNT of REIMBURSEMENT REQUESTED
a. Actual Cumulative Funds Expended
$
b. Total Funds Previously Received
$
c. Amount of this cash request
$
CERTIFICATION:
I certify to the best of my knowledge and belief the
data above is correct and that all expenditures were
made in accordance with grant agreements.
SIGNATURE OF
AUTHORIZED OFFICIAL:
DATE REPORT SUBMITTED:
NAME AND TITLE:
(Type or Print)
PHONE #:
( )
EMAIL ADDRESS:
CSBG RECOVERTY ACT
MONTHLY
DUE THE 20m OF EACH MONTH
REQUEST FOR REIMBURSEMENT REPORT
Copies of backup information (receipts, invoices, signed timesheets, etc.) must be
provided with the Reimbursement Report. The backup information must equal the
amount being requested, detailed in the Statement of Project (SOP), and be within the
timeframe of the contract.
MAIL TO:
CSBG
DOLA - DLGS
1313 Sherman Street - Room 521
Denver, CO 80203
ATTN: Lucia Smead
TYPE OF PAYMENT:
— Reimbursement
_ Final
REPORTING AGENCY:
(Name and Remit Address)
PERIOD COVERED BY THIS REQUEST:
From: To:
PAYMENT REQUEST NUMBER:
#
CONTRACT ENCUMBRANCE
NUMBER:
L10CSBG R
(Mo/Day/Yr) (Mo/Day/Yr)
COMPUTATION OF AMOUNT of REIMBURSEMENT REQUESTED
a. Actual Cumulative Funds Expended
$
b. Total Funds Previously Received
$
c. Amount of this cash request
$
CERTIFICATION:
I certify to the best of my knowledge and belief the
data above is correct and that all expenditures were
made in accordance with grant agreements.
SIGNATURE OF
AUTHORIZED OFFICIAL:
DATE REPORT SUBMITTED:
NAME AND TITLE:
(Type or Print)
PHONE #:
( )
EMAIL ADDRESS:
CSBG RECOVERTY ACT
MONTHLY
DUE THE 20TH OF EACH MONTH
REQUEST FOR REIMBURSEMENT REPORT
Copies of backup information (receipts, invoices, signed timesheets, etc.) must be
provided with the Reimbursement Report. The backup information must equal the
amount being requested, detailed in the Statement of Project (SOP), and be within the
timeframe of the contract.
MAIL TO:
CSBG
DOLA - DLGS
1313 Sherman Street - Room 521
Denver, CO 80203
ATTN: Lucia Smead
TYPE OF PAYMENT:
— Reimbursement
_ Final
REPORTING AGENCY:
(Name and Remit Address)
PERIOD COVERED BY THIS REQUEST:
From: To:
PAYMENT REQUEST NUMBER:
#
CONTRACT ENCUMBRANCE
NUMBER:
L10CSBG R
(Mo/Day/Yr) (Mo/Day/Yr)
COMPUTATION OF AMOUNT of REIMBURSEMENT REQUESTED
a. Actual Cumulative Funds Expended
$
b. Total Funds Previously Received
$
c. Amount of this cash request
$
CERTIFICATION:
I certify to the best of my knowledge and belief the
data above is correct and that all expenditures were
made in accordance with grant agreements.
SIGNATURE OF
AUTHORIZED OFFICIAL:
DATE REPORT SUBMITTED:
NAME AND TITLE:
(Type or Print)
PHONE #:
( )
EMAIL ADDRESS:
Hello