HomeMy WebLinkAboutCA State Water Resources Control Board - Wter Recycling Funding Program - D2101056 - Reimbursement RequestINVOICE DATE:
AGREEMENT NO.:
PROJECT NO.:
Signature of the Recipient's Authorized Representative Date
BYFUNDING DESCRIPTION PROGRAM NO.RECEIPT NO.
STATE USE ONLY: APPROVAL FOR PAYMENT
Disbursement Manager Signature Date
Authorized Manager Signature Date
Form 261 (Revised 11-8-21)
TOTAL REIMBURSEMENT APPROVED FOR THIS REQUEST:
Reason(s) for Adjustment:
RECIPIENT CERTIFICATION
By signing this reimbursement request I certify, under PENALTY OF PERJURY, in addition to other legally available penalties, each of the following:
(1) This document was prepared, and any attachments were added, by me or under my direction in accordance with the terms and conditions of the Agreement (number listed above) and, to the best of my knowledge and belief, is
accurate. (2) I have paid, or can certify as to the payment of, any and all fees due to the State Water Resources Control Board (State Water Board). (3) I have satisfied, or can certify as to the satisfaction of, all conditions in the
Agreement that must be satisfied prior to the disbursement of the funds in this reimbursement request. (4) The costs claimed in this reimbursement request have been incurred and have been paid or will be paid within thirty (30)
days of receipt of the funds requested hereby. If such costs have not been paid within 30 days, funds received under this request will be returned to the State Water Board. (5) All prior funds received from this Agreement have been
disbursed within 30 days of receipt or have been returned to the State Water Board. (6) All amounts included in this invoice are for costs incurred for the Project and represent only costs authorized under the Agreement that are
within the Agreement’s approved scope of work and budget. (7) The Agreement might or might not include authority for indirect charges. I certify that any indirect charges included in this request are in accordance with the
Agreement.(8) I am aware that there are significant penalties for submitting false or misleading information.
REQUESTED REIMBURSEMENT AMOUNT:
AMOUNT
INVOICE NO.:
PURCHASE ORDER NO.
DIVISION OF FINANCIAL ASSISTANCE
ATTN: DISBURSEMENT UNIT 16th Floor
POST OFFICE BOX 944212
SACRAMENTO, CA 94244-2120
REIMBURSEMENT AMOUNT APPROVED:
FI$CAL SUPPLIER ID NO.:
FUNDING LINE PAYMENT ALLOCATION (ACCOUNTING DETAIL)
FOLLOWING SECTION TO BE COMPLETED BY RECIPIENT
CALCULATION FOR REIMBURSEMENT
FOLLOWING SECTION IS FOR STATE USE ONLY
REIMBURSEMENT REQUESTED AMOUNT:
ADJUSTMENT AMOUNT:
STATE OF CALIFORNIA
STATE WATER RESOURCES CONTROL BOARD
REIMBURSEMENT REQUEST (INVOICE)
TO: STATE WATER RESOURCES CONTROL BOARD
Analyst Signature:
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DATE STAMP
FROM:
ELECTRONIC SUBMITTAL TO:
BILLING PERIOD: