Docstoc

Voucher

Document Sample
Voucher Powered By Docstoc
					                                        VOUCHER AND PRACTICE CERTIFICATION SUMMARY FORM
   A      PAYEE INFORMATION                                 Check if name or address change                           B         PRACTICE INFORMATION
Name                                                                                                           I.D. Number


Address                                                                                                        BWSR Program

                                                                                                                                                  Base Grant      Competative     FWQMG           Other Allocation
City, State, Zip Code                                                                                          Tons of Soil Saved            Sediment Reduction   Phosphorus Reduction



          Cost
   C                            Basis of Request                                                               Type of Request                                     Total Cost of Project
          Information
                                         Installation                              Reinstallation                     Partial      Final                          $
  R/I                                  ITEM                                           QUANTITY                       UNIT                  UNIT PRICE                                   COST
                                                                                                                                                                                                                   $0.00
                                                                                                                                                                                                                   $0.00
                                                                                                                                                                                                                   $0.00
                                                                                                                                                                                                                   $0.00
                                                                                                                                                                                                                   $0.00
                                                                                                                                                                                                                   $0.00
                                                                                                                                                                                                                   $0.00
                                                                                                                                                                                                                   $0.00
                                                                                                                                                                                                                   $0.00
                                       (attach additional sheets as necessary)
                                                                                                                                                        TOTAL                                                      $0.00
R: Receipt/Invoiced Item                 I: In-kind Contribution

I certify that this is an accurate and true summation of the actual costs and quantities of material, labor, and equipment used on the above project. In cases where the receipts included items not used on the
project, I have corrected them accordingly.


                                               (Payee Signature)                                                                             (Date)
   D      PAYMENT INFORMATION


TOTAL COST OF PRACTICE                                                       [c above]
                                         $
PROGRAM COST-SHARE
                                                                             [from box e]       (a) Total of Previous Payments
PAYMENT                                   $                                                                                                  $

                                                                                                (b) Cost-Share Payment Request
Other Funding Sources (Please identify source)                                                                                               $

                                         $
                                         $                                                      COST-SHARE PROGRAM [(a) + (b) cannot exceed 75% of (c)]

                                         $                                                      (c) Total Cost Approved                      $

                                         $                                                      (d) Other Public Funds                 % $

                                         $                                                      (e) District Share                     % $
LAND OWNER/LAND
OCCUPIER COST
                                =                                   $0.00
                                         (attach additional sheets as necessary)

    E TECHNICAL CERTIFICATION                               ADMINISTRATIVE CERTIFICATION                                        CONSERVATION DISTRICT BOARD PAYMENT APPROVAL
I certify that an inspection has been performed and that    I certify that I have reviewed this voucher and all supporting
the items identified in part c have been complete and are   information and that to the best of my knowledge and belief,
in accordance with the requested practice standards and     the quantities and billed cost or disbursements are accurate
specifications.                                             and are in accordance with terms of the program identified.




DISTRICT REPRESENTATIVE with TAA                            ADMINISTRATIVE SIGN-OFF DESIGNATED SWCD REP.                        CONSERVATION DISTRICT BOARD CHAIRPERSON
Date                                                        Date                                                                Date

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:118
posted:12/20/2011
language:
pages:1