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r , <br /> 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: McClave Water Association ,,, <br /> Phone#: 719-829-4003 <br /> POBox73 <br /> McClave,CO 81057 ' r/t f <br /> A f� <br /> 1. <br /> Project Number: OE PDA 14IBC000006 <br /> Pay Request Number: Five-A Check here for final payment q <br /> Expenditures: From: 03/29/2014 To: 04/25/2014 <br /> Contract Amount: $ 64,300.00 <br /> Previous Amount Paid: $ 62,422.81 <br /> Total Invoice Amount: $ 1,877.19 <br /> Grant Contract Balance: $ 0.00 <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: Carrigan Excavating,LLC <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 /> ttached. <br /> .O _,..__ May 13,2014 <br /> Authoriz• Representative 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 /> 74 me i s authorized. <br /> Adra allhlo <br /> .j.domk 5*2/4)/4- <br /> 'r,'ect "anager Dat <br /> n <br /> r I , I v Date <br /> Rebecca Mitchell <br /> Rev 11/13 <br />