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