"Post ARRA PAYMENT REQUEST FORM Revised 6 6 12"
REIMBURSEMENT REQUEST FOR CWSRF and DWSRF CHECK LIST UPDATED 6-7-12 INCLUDED ITEM Include Cancelled Checks For Previous Reimbursement Request Reimbursement Request No. filled in All Invoices included from Vendors Total Cost Calculated Davis Bacon Certifications Received For Final Reimbursement Request include MBE/WBE Utilizatoin Form 5700-52A and Check 1B for "Last Report" For Final Reimbursement Request include Cancelled Checks for Current Reimbursement Request REIMBURSEMENT REQUEST FOR CWSRF and DWSRF REQUEST FOR REIMBURSEMENT OF EXPENSES State of Vermont - Department of Environmental Conservation 1. Enter Reimbursement Request Number. 2. List separately all invoices being submitted for reimbursement. Invoices must have been paid. 3. Cancelled checks from the bank are not required to process the first request; they are required before the next request will be processed. 4. Attach invoices to this form. 5. Form must be signed by the Authorized Representative of the project. 6. Mail to: Facilities Engineering Division, 103 South Main Street, Laundry Building, Waterbury, VT 05671-0511 7. Please do not write in areas within bold lines. 8. Fill in Pages 1, 2 and 3 Municipality Name Loan Number Reimbursement Request No. # Vendor Invoice Number Date Paid Check # Amount OFFICIAL USE ONLY $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ RECOVERY CALCULATIONS TOTAL COSTS $ $ Total Planning Paid $ Project Percentage % Prior Recoveries $ Reimbursement Amount $ Recover This Request $ Adjustments $ Recovered to Date $ NET Reimbursement $ Previous Reimbursements $ ** SHADED AREAS ARE FOR DEPARTMENT USE ONLY Total Reimbursed To Date $ Total Project Amount $ Percent of Funds Reimbursed % REIMBURSEMENT REQUEST FOR CWSRF and DWSRF Page 2 - Certifications and Additional Information Certification - Davis Bacon Act The Davis Bacon Act Certification applies only to: 1. Projects with loans, or amendments to loans, that were executed after 10/30/09, and 2. Had construction that occurred after 10/30/09 Check if applies The authorized representative as listed below hereby certifies that they have obtained weekly payroll certification on OMB form 1215-0149, or equivalent, from each contractor working on the Project; and will keep copies in their project files for at least three years from time of reimbursement. This certification also acknowledges that the required Davis Bacon Posters "Wage Determinations" and "DOL 'Notice to Employees" posters are available to employees at or near the worksite. Final reimbursement Request Check boxes if this is the Final Reimbursement Request. All Invoices and Cancelled Checks Have Been Included Final MBE/DBE Utilization Report Form 5700-52A is Included Certification for Reimbursement I certify that to the best of my knowledge the information on these forms is correct and all costs submitted have been paid in full. The Authorized Representative's signature below certifies agreement with the above Certification. Date Signature of AUTHORIZED REPRESENTATIVE Date Signature of State Official Facilities Engineering Division