Laserfiche WebLink
ACTIA 2002-26.01 <br />APPENDIX A <br />REQUEST FOR REIMBURSEMENT <br />Contract Summary by Vendor <br />Original Contract Amount: <br />TOTAL CONTRACT AMOUNT: <br />Sponsor: <br />ACTIA Project No: Amount Billed Prior: <br />PHASE: Amount of this Invoice: <br />Report Mo/Yr.: Remaining Budget: <br />Date Submitted: <br />Vendor <br />No.* <br />Vendor <br />Level of <br />Subcontract** <br />Certification <br />Contract <br />Award <br />Amount ($) <br />Percent of <br />Contract <br />Amount <br />Previous <br />Invoices <br />Current <br />Invoice <br />Total <br />Invoiced -to- <br />Date <br />ACTIA Total <br />Paid -to - <br />Date <br />% of Invoiced - <br />to -Date vs. <br />Contract <br />Amount <br />Prime <br />TOTAL <br />Summary of Goal Participation"* <br />DBE <br />LBE <br />SLBE <br />Vendor No.* <br />Tier <br />Goal 1 <br />To Date 2 <br />Goal 1 <br />To Date 2 <br />Goal 1 <br />To Date 2 <br />TOTALS <br />*Furnished by ACTIA <br />**Breakdown to Tier 1 subcontractors unless a lower tier is used in goal achievement <br />*** When applicable <br />Note 1 — Goals based on Current Contract Amount <br />Note 2 — Based upon payment to date <br />McGOru Of rd rrlCrll W .7Uua <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 />Signature <br />Date <br />ACTIA USE ONLY — Supporting documents review and approved for payment <br />Signature <br />Date <br />Page C-2 <br />