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REQUEST FOR REIMBURSEMENT <br />Contract Summary by Vendor <br />Original Contract Amount: <br />TOTAL CONTRACT AMOUNT: <br />Sponsor: <br />ACTIA Project Na: <br />PHASE: <br />Report Mo/Yr.: <br />Date Submitted: <br /> <br />Vendor <br /> <br />No.* <br /> <br />Vendor <br />Level of <br /> <br />Subcontract** <br /> <br />Certification Contract <br /> <br />Award <br />Amount ($) Percent of <br /> <br />Contract <br />Amount <br />Previous <br /> <br />Invoices <br />Current <br /> <br />Invoice Total <br /> <br />Invoiced-to- <br />pate AC71A Total <br /> <br />Paid-to- <br />Date % of Invoiced- <br />to-Date vs. <br /> <br />Contract <br />Amount <br /> Prime <br /> <br /> <br /> <br /> TOTAL <br />Summary of Goal Participation*** <br /> D BE LBE SLBE <br />Vendor No.* Tier Goal (1) To Date (2) Goal 1 To Date 2 Goal 1 To Date 2) <br /> <br /> <br /> <br /> <br />TOTALS <br />*Furnished by ACTIA <br />'"l3reakdown to Tier 1 subcontractor*s unless a tower tier is used in goal achievement <br />*** When applicable <br />Amount Billed Prior: <br />Amount of this Invoice: <br />Remaining Budget: <br />rcecora or ra meni to nuns <br />Vendor Date Last Amount <br />No.* paid paid to <br />Date <br />Project Manager's Assurance: <br />I hereby certify that the information included in this <br />Request for Reimbursement is true and accurate. <br />Note 1 -Goals based on Current 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 />Page A-2 <br />