Billing Statement by vtx18811

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									                                                                 Request for Reimbursement
                                                                          Sub-Grantee Name:__________________
Kentucky Office of Homeland Security                                                                              Date:
                                                                                              Sequence #:
Agreement:           PO2-094-___________________
Project #:           08-________                                Check this box, if this is the final request:
Sub-grantee:         ___________________________                                           Final Payment will not be made
Mailing address      ___________________________                                           without the required inventory
                     ___________________________                                           listing attached.
                     ___________________________
      Date                                 Description of Items Purchased                                        Amount




                     Continuation from page 2                                                          Subtotal:                                  $0.00
                                                                                                                          Total Requested
                                                                                                                                                  $0.00

This form was prepared by:                 ________________________________________                    Phone:             ____________________
                                              Name (Please Print)

Sub-grantee Certification: I hereby certify that the costs incurred are taken from the books of account and that such costs are valid and consistent
with the terms of the contract and all original backup documentation is maintained. I also certify none of the vendors used in purchasing these
items were on the Federal Excluded Parties Listing prior to purchase. And that the following documents are either attached or on file at KOHS: (1)
NIMS, (2) KWIEC Approval or Wavier, (3) KSP MOUs. I hereby certify that this agency is in compliance with the A-133 Audit requirements. I
certify that all items were purchased from a State Price Contract listing when available.

Name:_____________________________________________________________ Title:________________________________________
                  Authorizing Person (Please Print)


Signature: __________________________________________________________Date:_________________________
                  Authorized Signature (Original Signature Required


KOHS Use Only: KOHS Grant Manager Approval _______________________________________________________________Date:___________________


KOHS Use Only: KOHS Grant Supervisor Approval _____________________________________________________________Date:____________________


                                                               Mail Requests to:
                                                      Kentucky Office of Homeland Security
                                                                    200 Mero Street
                                                                  Frankfort, KY 40622


                                                                         Request for Reimbursement
                                                                         Sub-Grantee Name:_______________

                                                                                                   Date:
Agreement:       PO2 094-_____________________                                                Sequence #:
Project #:       08-_________


                                       Continuation Sheet       Page 2
     Date                                     Description of Items Purchased                                         Amount




                                                                                                            Total Requested
                                                                                           Subtotal                              $0.00

Signature: __________________________________________________________Date:_________________________
              Authorized Signature (Original Signature Required

KOHS Use Only: KOHS Grant Manager Approval _______________________________________________________________Date:___________________
KOHS Use Only: KOHS Grant Supervisor Approval _____________________________________________________________Date:____________________

								
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