HomeMy WebLinkAbout1 - Original Submission_ 2023 Contract Exhibit C - Voucher (2)EXHIBIT C - VOUCHER
To:From:
Attn:Contact:
Address:
Contract #
*Request Period:
*NOTE: request period must be after notice to proceed date
□
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
50,000.00$ -$ -$ -$ 50,000.00$
$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 - KCR
DocuSign Envelope ID: 7B0A24CE-44D7-48A4-8276-36F7E3961578