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DEPARTMENT Encumbrance Worksheet Grant <br />OF HEALTH <br />Vendor Name & Doing Business As (DAM when applicable): <br />City of Ramsey (DBA Name 2 — Finance) <br />Vendor Number: <br />0000199282 <br />Vendor Location Code: <br />001 <br />Vendor address: <br />7550 Sunwood Drive NW, Ramsey, MN 55303 <br />Vendor Remit -to Address (if i ... erent : <br />Requestor's Name & Employee ID#: required by SWIFT. <br />� 9 � <br />Eddie Wojski / 0//28746 <br />Certified TG/ED .VD Vendor <br />❑ Yes <br />® No Not applicable for grant <br />Starting State Fiscal Year: <br />2021 <br />Amount of Original Agreement: <br />.............................................................. . <br />$9,600.00 <br />Agreement Start Date: <br />January 8, 2021 <br />.. ................................................................................. . <br />....................................................................................... ..... . <br />Amount of Original + ALL Previous Amendments: <br />reement End Date: <br />December 31, 2021 <br />Amount of this Amendment ONLY: <br />Amended End Date: <br />Grand ;Total Original + alI Amendments <br />g : <br />j. <br />$9,600.00 <br />Language Only <br />Time Only <br />Money Only: <br />Time and Money <br />El <br />Special Instructions: <br />Does this contract contain non-public data? ❑ Yes ® No <br />If "Yes" provide a Contract/PO description for SWIFT: <br />ACCOUNTING INFORMATION <br />State . Fiscal Year 2021 <br />Fund <br />Dept ID <br />Appr ID <br />Project ID <br />Activ <br />tY <br />D: <br />Amount <br />Project Funding <br />Start Date <br />2302 <br />H1232117 <br />H12162P <br />$9,600.00 <br />7/1/2020 <br />H123 <br />H12 <br />H123 <br />H12 <br />State Fiscal Year 202 <br />.... ... .... ... ... .... <br />Fund <br />Dept ID <br />Appr ID <br />Project ID <br />Activity ID <br />Amount <br />Project Funding <br />Start Date <br />H123 <br />H12 <br />H123 <br />H12 <br />H123 <br />H12 <br />$ <br />State Fiscal Year 202 <br />Fund <br />Dept ID <br />Appr `ID <br />Project ID <br />Activity ID <br />Project Funding <br />Start Date <br />H123 <br />H12 <br />H123 <br />H12 <br />H123 <br />H12 <br />$ <br />FINANCIAL MANAGEMENT USE ONLY <br />Encumbrance Signature <br />Contract Number <br />Sarah Martin <br />186689. <br />Digitally signed by Sarah Martin <br />Date: 2020.12.09 07:45:23-06'00' <br />Date <br />Origin Code <br />Purchase Order Number <br />3000081148 <br />Source Type <br />Category Code <br />84101501 <br />Account ID <br />441352 <br />Revised 5/19 <br />