Laserfiche WebLink
APPENDIX D-1 <br />REQUEST FOR REIMBURSEMENT <br />Contract Summary by Vendor <br />Original Contract Amount: <br />TOTAL CONTRACT AMOUNT: <br />Sponsor: <br />ACTIA Project No: <br />PHASE: <br />Report Mo/Yr.: <br />Date Submitted: <br />Amount Billed Prior: <br />Amoun# of this Invoke: <br />Remaining Budget: <br /> Of <br /> <br />Vendor <br />Level of Contract Percent of <br />Previous <br />Currant Total ACTIA Total Invoiced- <br /> <br />No * Vendor <br />Subcontract""' Certiflcatlon AwaM Contract <br />Invoices <br />Invoice Invoiced-to- Paid-to- to-Date vs. <br /> Amount (;) Amount Date Date Contract <br /> Amount <br /> Prime <br /> <br /> TOTAL <br />Summary of Goal Participation'""' <br /> D BE LBE ELBE <br />Vendor No.' Tler Goal 1 To Date 2 Goal 1 To Date 2 Goal 1 To Date 2 <br /> <br /> <br /> <br />TOTALS <br />*Fumfshed by ACTIA <br />"'Breakdown to Tier 1 subcontractors unless a lower tier Is used In goal achievement <br />induded in this <br />*'* When applicable <br />accurate. <br />Note 1 -Goals based on Curtent Contract Amount <br />Note 2 -Based upon payment to date <br />Signature <br />Date <br />ACTIA USE ONLY -Supporting documents review and approved for payment <br />Signature <br />Date <br />tcecora or ra meni io suos <br />Vendor Date Last Amount <br />No' paid Paid to <br />Date <br />I hereby certify that the information <br />Request for Reimbursement is true and <br />ACTIA 11: I-880 /Washington Avenue Interchange Improvements June, 2005 <br />COSL Project No. 144-39-007 Page 34 of 35 <br />