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LCMR Pass Through Program <br />Payment Request Form <br />Project Contract <br />Number: <br />Recipient: <br />Project Name: <br />Request Number <br />Period for which funds are being <br />requested: <br />From: 1 I To: <br />1 I <br />Amount of Request $ <br />I certify that I am the individual authorized to request funds; that all <br />expenditures reported have been dispersed and are in accordance with <br />the contract agreement, and all original documentation is retained at <br />our offices in the form of invoices, canceled checks, and signed time <br />records. Copies of these documents are attached as evidence of <br />payment. <br />Signature Date <br />Name Title <br />Phone Number: <br />Remarks: <br />For Department Use Only <br />I have reviewed the evidence provided by the recipient <br />for the goods, materials and/or services presented and <br />they are eligible for reimbursement under the work <br />program. <br />Payment approved in the amount of $ <br />FY <br />, <br />Vendor Number (9) <br />Dept <br />Invoice # (20) <br />Contract # <br />Line # <br />Object # <br />By <br />Payment Amount: <br />Date <br />Transaction <br />Date/No. <br />Dept. Auth. Signature <br />Reminder: Please be sure to attach copies of invoices and evidence of payment as documentation for reimbursements. <br />29 <br />D:\William H. Becker ZIIILCMR\LCMR Pass Through\2003 Agreements\City of Ramsey Metro Agreement.doc <br />9/4/2003 <br />