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HomeMy WebLinkAboutAR Invoice Request Form-FillCUSTOMER INFORMATION BILLING INFORMATION FOR FINANCE USE ONLY: AR No. Invoice No. CERTIFICATION CONTRACT INFORMATION (if applicable) Finance Routing: Grants—Kristin Trivelas Other—Sandra Pedersen FOR FEDERAL GRANTS (INCLUDING PASS-THROUGH) Phone: AR Invoice Request Date: Authorized By: Department Name: Customer Name: AR Customer No. Address: Contact/Attn: Email/Phone: Mailing Address (if different): CAG#: Expiration Date: Invoice Title (Eden Description—21 character limit): Invoice Description (Printed on Invoice): Account Number Amount Final Invoice? Type of Billing: Invoice Total: Do not mail Mail invoice only Mail invoice w/ backup Email invoice to: Special Instructions for AR: By signing this report, I certify to the best of my knowledge and belief that the report is true, complete and accurate, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. Date: Signature/Printed Name 11-16-2020 Jason A. Seth x6502 ASD - City Clerk Milton Orellana 451 Duvall Ave NE, Suite 115, Renton, WA 98059 Milton Orellana milton@aterahomes.com /425-306-2758 Appeal to HEX - N 29 Appeal to HEX - n 29th Modification (Alley Modification) 000.000000.011.345.81.00.000 500.00 500.00 milton@aterahomes.com as soon as payment is received let Jason Seth, City Clerk know