Reimbursement Request

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					                               COMMISSIONERS
                               Jimmy Dimora
                               Timothy F. Hagan
                               Peter Lawson Jones                                   REQUEST FOR REIMBURSEMENT



Municipality                                                                        Street Address & Zip Code



Contact Person                                                                      Telephone Number & Area Code

                                                                                    E-Mail
Contract Number / Grant Year
                                                                                    Activity
Payment Type:                  Partial
                               Final                                                Contract Period



Contract Amount:
Received To Date:                                                             Precentage of work completed:
Unpaid Prior Request:                                                        Comments:
This Request:
Balance Availabe:              $                   -


                      PROJECT INFORMATION                                                              Type of Project
Census Tract
Block Group                                                            Infrastructure Improvements
                                                                       Sanitary Sewer Maintenance
                      CONSTRUCTION                                                      Streetscape
Start Date                                                                     ADA Improvements
Completion                                                                                     Other


                      JOB CREATION                             Notes/Special Instructions
Full Time
Part Time


                                                 Check the type of Doucumentation Attached
             Payroll Reports                                             Invoices                      Other (specify)
  Monthly Utilization Report                                  Cancelled Checks


I certify that to the best of my knowledge the above data is correct and funds will be reimbursed in accordance with the provisions of the contract.




Signature of Official                                          Name Typed or Printed

Date                                                           Title
          MUNICIPAL GRANT BUDGET SUMMARY
                                      Cuyahoga County Department of Development

Community :                                                                             Request Number:
Project Name:                                                                           Date of Request:
CDBG Amount:                                                                            Contract #/Year:

                                BUDGET                                                         EXPENDITURES

  **Budget Line   County CDBG      City of      Other Funding Total Budget      Previous         Qualified     Total to Date    Balance
      Item                                                                    Costs Incurred      Costs
                                                                                               Incurred this
                                                                                                  Period
                                                                      $0.00                                             $0.00        $0.00
                                                                      $0.00                                             $0.00        $0.00
                                                                      $0.00                                             $0.00        $0.00
                                                                      $0.00                                             $0.00        $0.00
                                                                      $0.00                                             $0.00        $0.00
                                                                      $0.00                                             $0.00        $0.00
                                                                      $0.00                                             $0.00        $0.00
                                                                      $0.00                                             $0.00        $0.00
                                                                      $0.00                                             $0.00        $0.00
                                                                      $0.00                                             $0.00        $0.00
Contingencies                                                         $0.00                                             $0.00        $0.00
Architectural/                                                        $0.00                                             $0.00        $0.00
Engineering
Administrative                                                        $0.00                                             $0.00        $0.00


     TOTAL              $0.00           $0.00                         $0.00           $0.00            $0.00           $0.00         $0.00




                                                 COUNTY REIMBURSEMENT
                  "Qualified Costs" Incurred this Period                      x Rate Per          =Reimbursement
                                 (from table above)                             Contact               Amount
                                             $0.00                                                      $0.00

                                “Qualified Costs” are those cost which are eligible per the contract.

                  **BUDGET LINE ITEMS MUST MATCH BUDGET PAGE OF THE CONTRACT.
                     MUNI GRANT REIMBURSEMENT
                        BUDGET DETAIL FORM

            Community :
          Project Name:
       Contract # / Year:

           BUDGET CATEGORY:

                                                    Invoice
                                                   Number or
DATE         CHECK #               PAYEE           description   AMOUNT




                                   TOTAL                         $        -

           BUDGET CATEGORY:

                                                    Invoice
                                                   Number or
DATE         CHECK #               PAYEE           description   AMOUNT




                                   TOTAL                         $        -

           BUDGET CATEGORY:

                                                    Invoice
                                                   Number or
DATE         CHECK #               PAYEE           description   AMOUNT




                                   TOTAL                         $        -


                            GRAND TOTAL (page 1)   $                 -
                     MUNI GRANT REIMBURSEMENT
                        BUDGET DETAIL FORM

            Community :

         Project Name:
       Contract # / Year:

           BUDGET CATEGORY:

                                                         Invoice
                                                        Number or
DATE         CHECK #                 PAYEE              description   AMOUNT




                                      TOTAL                           $        -

           BUDGET CATEGORY:

                                                         Invoice
                                                        Number or
DATE         CHECK #                 PAYEE              description   AMOUNT




                                      TOTAL                           $        -

           BUDGET CATEGORY:

                                                         Invoice
                                                        Number or
DATE         CHECK #                 PAYEE              description   AMOUNT




                                      TOTAL                           $        -


                            GRAND TOTAL (pages 1 & 2)   $                 -

				
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