HomeMy WebLinkAbout1 - Original Submission_ 2023 Contract Exhibit C - Voucher YWCAEXHIBIT C - VOUCHER
To:From:
Attn:Contact:
Address:
Contract #
*Request Period:
*NOTE: request period must be after notice to proceed dateā”
1 Personnel
Services -$ -$
2
Supplies and
Equipment (Office
supplies,
class/event equipment)-$ -$
3 Administration
(see Budget form
for details)-$ -$
4
Indirect Admin
Expenses (specify)-$ -$ -$ -$ -$
6
Client Direct
Services (See
Budget form for
details) -$ -$ -$
9 Other (describe)-$ -$ -$ -$ -$
10
Applicable Credit (tuition charged)
Amount will
automatically
deduct from the
Total Request amount
83,000.00$ -$ -$ -$ 83,000.00$
$0.00
I am aware that any false, fictitious, or fradulent information, or the omission of
any material fact, may subject me to criminal, civil or administrative penalties
for fraud, false statements, false claims or otherwise (U.S. Code Title 18, Section
1001 and Title 31 Sections 3729-3730 and 3801-3812)
City of Bremerton
Community Development
This voucher reimbursement is for activities/services rendered under the housing and community development block grant (CDBG)
identified as:
Project Name:
Voucher #:
CDBG Staff
345 6th Street, Ste 100
Bremerton, WA 98337-1873
Check here if this is a final reimbursement request.
Cost Categories Budget Award Revised
Budget*
(if applicable)
Total Prior
Requests
that the report is true, complete and accurate, and the expenditures, disbursements, and cash reciepts are for the purposes and
objectives set forth in the terms and conditions of the Federal award
AUTHORIZED SIGNATURE (AS SET FORTH IN THE
AGREEMENT)
*All budget revisions must receive CDBG approval
Voucher Reimbursement Request
Housing and Community Development Block Grant Program
Date:
Total This
Request
Total Requested
to date
Award Balance
Remaining
Grand Total
By signing this report, I certify to the best of my knowledge and belief
2023 Subrecipient Agreement - YWCA
DocuSign Envelope ID: 57A8290C-5919-442A-AB9D-94D7E2364C6D