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REQUEST FOR REIMBURSEMENT <br /> TO: Colorado Water Conservation Board,Department of Natural Resources <br /> Water Supply Planning Section <br /> 1580 Logan Street,Suite 200 <br /> Denver,CO 80203 <br /> ATTN: Jacob Bornstein,Program Manager <br /> FROM: ;` '`r e i e Phone#: 719-829-4003 <br /> PO Box 73 <br /> McClave,CO 81057 <br /> i't 410440 t 4.4111....J 00116 <br /> Pay Request Number: One Check here for final payment <br /> Expenditures:From: 09/28/2013 To: 10/25/2013 <br /> Contract Amount: $ 64,300.00 <br /> Previous Amount Paid: $ 0.00 <br /> Total Invoice Amount: $ <br /> Grant Contract Balance: $ 60,848 88 <br /> The person,firm or corporation to whom the amount requisitioned is due,or to whom a reimbursable and advance <br /> has been made,is: GMS,Inc.,Consulting Engineers <br /> Please make check payable to: McClave Water Association <br /> This is to certify that the above expenses were incurred according to the grant agreement and invoices are <br /> hed. <br /> Authorized;'epresentative Signature Date <br /> Doug Smartt President <br /> Authorized Rep(Typed or Printed) Title <br /> To be completed by the Colorado Water Conservation Board,Dept of Natural Resources. <br /> I hereby certify that all contract requirements have been met and the amounts billed are correct. <br /> Payment is authorized. <br /> Project Manager Date <br /> Rev 11/13 <br />