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HomeMy WebLinkAboutGrant Related - BOCC (003)GRANT COUNTY BOARD OF COUNTY COMMISSIONERS To: Board of County Commissioners From: Janice Flynn, Administrative Services Coordinator Date: December 16, 2021 Re: Authorization for Release of Funds, Dept of Commerce, CDBG CV1 #20- 6221 C-111, Reimbursement #7, Subrecipient O/C Request #7 OIC has requested reimbursement regarding the above -referenced grant in the amount of $13,570.65 for October 2021 expenses. Their documentation is attached for review. I am requesting the release of funds for payment to OIC in the amount of $13,570.65 Thank you. [Dated this '09A day o , f Yk& 20 -A Board of County Commissioners Grant County, Washington Approve Disapprove Abstain Dist #I Dist# I Dist # I Dist # - -9 Dist # 2 Dist # 2 Dist #3 Dist # 3 Dist # 3 i STATE OF WASHINGTON DEPT OF COMMERCE ATTN: CDBG PROGRAM PO BOX 42525 OLYMPIA, WA 98504-2525 SUBRECIPIENT: OIC OF WASHINGTON 815 FRUITVALE BLVD YAKIMA WA 98902 TOTAL AMOUNT REQUESTED THIS PERIOD.-. CDBG Public Services Expenditure Report CDBG CONTRACT NO: 20-6221 C-111 REPORT MONTH: E Oct -21 REPORT NUMBER: 13 .................................. $13.3570.65 COMMUNITY DEVELOPMENT BLOCK GRANT - CV GRANTS M11 -I'm vnq���� CERTIFICATION: I certify that the information on this form is a true and accurate report of the cash status and that all reported expenditures are properly chargeable to the referenced grant. Signature: Printed Name: DEREJE MEKURIA Title: CFO Date: 11/29/2021 P'r� a-,* I - 'c activities this pe * -)d-: $76.55 1 - Name of Service 'alh; HOUSING CDBG CV jjCDB;3 amount �requesft,',-d for these program n, Description of service program and how low- and moderate -income (LMI) persons Avere served this period: Assistance was advertised by radio, print and social media to targeted areas and qualifying loci-seholds throughout the service area. 2. Name of Service Pro eram: SUBSISTENCE CDBG CV j[CG amount Tequested for these ogram activities this period-., $12-0146.56 Delsl,scdiption , of service program how low- and moderate -income (LMI) persons were served this period: Assistance was advertised by radio, print and social media to targeted areas and qualifying house'holds throughout the service area. av 0 - T71 A �, ''I'.1N1STRAM HOUSING/SUBSIST 'C! S1.147.54 Name of Service Program Description of service program how low- and moderate -income (LMI) persons were served this period: General administration expenses associated with managing Housing and Subsistence activities overs igglit and assessments. Indirect admin. CDBG Public Services Expenditure Report S'K'ATE OF WASHINGTON COMMUNITY DEVELOPMENT BLOCK GRANT - CV GRANTS DEPT OF COMMERCE E"RISE A.TTN: CDBG PROGRAM Pt) BOX 42525 CERTIFICATION: I certify that the information on this form is a OLYMPIA, WA 98504-2525 true and accurate report of the cash status and that all reported expenditures are properly chargeable to the referenced grant. SUBRECIPIENT: CDBG CONTRACT NO: Signature: OIC OF WASHINGTON 20-6221 C-11 I 815 FRUITVALE BLVD REPORT MONTH: Printed Name:.DER.EJE MEKURIA ' YAKIMA WA. 98902 Oct -21 11 REPORT NUMBER: Title: CFO 13 Date: 11/29/2021 ;'TOTAL AMOUNT REQUESTED THIS PERIOD: $0.00 L Name of Service Pro ram: MICRO -ENTERPRISE IICDBG amount requested for these program activities thiseriod: $0.00 Description of service program and hoer low- and moderate --income (LMI) persons were served this period: Assistace was advertised to Micro -Businesses by radio, print, social media and face-to- face and assisted to financiatiy qualifying businesses within the service areas. 2. Name of Service program: ADMINISTRATION MICRO -ENTERPRISE CDBG amount requested for these 2rograrn activities thisperiod: $0-00` Description of service procrram how low- and moderate -income (LMI) persons were served this period: General administration expenses associated with managing .Micro -Enterprise activities oversight and assesments. Indirect Admin. OIC OF WASHINGTON For User: NGRID FRANK RW Expenditure report for: 500 - 500 CDBG CV I Page: Page 1 of 1 Date: 11/23/2021 Report year, 10/1/2020 thru 12/31/2023 Period ending: October 2021 Time: 1:06,34 PM —Monthly--- -----To Date— Account Budget Expenditures Pct Budget Expenditures Pct Annual budget Unexpended 62SB 62 Subsistence $3,060-00 $12,346.56 403,48% $391780.84 $33V317_51 83.75% $119,884-84 $86,567-33 63MC 63 Microenterprise $4,781.00 $0.00 0.00% $62,153.02 $17,152.46 27.60% $187,011.02 $169,858.56 64HS 64 Housing $4,603.00 $76.55 1.66% $59,839.74 $59,253-96 99.02% $180,117.74 $120,863.78 Adrnn Administration $27130.00 $1,147.54 53.88% $27,690.40 $8,249.60 29.79% $837103-40 $74,853-80 Report Totals $14,574.00 . =$13,570.65 9 .12% $189,464.00 $117,973.53 62.27% $570,117.00 $452,143.47 efxz General Ledger System OIC OF WASHINGTON For User: INGRID FRANK Page-- Page 1 of 5 Fund Expenditure report for: 500 - CDBG-CV1 10/1/20-12/31/23 (Fund status: Active) Date: 11/2312021 Report year: 10/112020 thru 12/31/2023 Period ending: October 2021 Time., 1:05:45 PM --Monthly- -To Account Budget Expenditures Pct Budget Expenditures Pct Annual budget Unexpe,nded., . . ... . . ............. . ...... ...... . ..... ... .... . . ............. Department: 009 IND R5 ADMIN Program: 02 ADMIN. POOL'55CS`E 5312 SALARY ADM. ALLOCATION $1,321.00 5354 P/R TAX & BEN- ADM ALLOC. $554-00 5999 NON PERSONNEL ADM. ALLOG. $255.00 $2,130-00 Total for sub program ---> Total for program 02 ----> Total for department 009 . . ... .... .. Department: PWO COVID 19 Program: 62 SUBSISTENCE 5311 SALARIEW��'AG�6$7W, SE -1 5351 FICA,OIC EXP 5352 LAND I,OIC SHARE 5353 STATE UCI(ES),OIC EXP 5355 PAID FAMILY MEDICAL LEAVE 5360 DISABILITY OIC EXPENSE 5361 MEDICAL INSURANCE,OIC EXP 5362 LIFE INSURANCE,OIC EXP 5363 PENS ION, OIC EXP 5364 ACCRUED PTO EXP 5402 AUDIT COSTS 5500 TRAVEL 5602 DEPRECIATION EXP EQUIP 5618 CLIENT MORTGAGE PYMENT 5619 HOUSING ASST/RENT 5700 CONSUMABLES 5712 REPRODUCTION SUPPLIES 5800 EQUIPMENT $2,130.00 $21130.00 $703.71 53.27% $318.61 57.51% $125.22 49.11% $2,340.36 '3_88% $13147.54 53-88% $1,147.54 53.88% $17,173.40 $4,942.59 28-78% $51,524.40 $46,581.81 $7,202.00 $2,340.36 32.50% $21,607-00 $19,266.64 $3,315-00 $966.65 29.16% $9,972.00 $9,005-35 I ........... - .. -.1.1 - $27,690.40 -1 ......... . ....... . .. .. $87249-60 29.79% $83,103.40 $74,853.80 $27,690.40 $8,249.60 29,79% $83,103.40 $74,853.80 $271690.40 $8,249.60 29-79% $83,103.40 $74,853.80 $814.00 $2,883-11 354-19% $10,582.06 $71732.750 73.07% $31,759.06 $24,026.31 $58.00 $215.21 371.05% $754.00 $586-16 77.74% $21276.00 $1,689-84 $7.00 $19.77 282.43% $91.00 $46.76 51.38% $302-00 $255.24 $19.00 $62.86 330.84% $247.00 $168.59 68-26% $778.00 $609.41 $3.00 $11.81 393.67% $39.00 $31.21 8003% $153.00 $121.79 $13.00 $41.45 318.85% $169.00 $60.44 35.7610 $512.00 $451.56 $258.00 $321.08 124.45% $31354.00 $327.15 9.75% $10,069-00 $9,741-85 $5.00 $16.52 330.40% $65.00 $24.13 37.12% $204.00 $179.87 $71.00 $206.8$ 291.38% $923.00 $576.33 62.44% $2,769.00 $21192.67 $89.00 $325.92 366.20% $11157-00 $325.92 28.17% $31498.00 $3,172.08 $25.00 $0.00 0.00% $43125.00 $0.00 0.00% $1,000.00 $1,000.00 $38.00 $0.00 0-00% $494-00 $0.00 0.00% $1,500.00 $1,500.00 $0.00 $2.64 0.00% $0.00 $8.68 0.00% $0.00 ($8.68) $641.00 $51250.00 19.03% $8,333.00 $7,725.50 92.71% $251000.00 $17,274.50 $128.00 C$2#875-00 -246.09% $1,664-00 $91246.10 555.66% $5,000.00 ($4,246.10) $76.00 $0.00 0.00% $988.00 $772.97 78.24% $3,000-00 $21227.03 $51.00 $31.19 61.16% $663.00 $43.24 6.52% $2,000.00 $1,956.76 $0.00 $0.00 0.00% $0.00 $333.68 0.00% $0.00 ($333.68) OIC OF WASHINGTON For User.- INGRID FRANK Fund Expenditure report for: Report year: 10/1/2020 Account 5601 5910 INSURANCE 5912 LIABILITY INSURANCE 5945 ADVERTISING 5949 STAFF TRAINING 5959 SERVICES 5960 COMMUNICATION 5970 POSTAGE Total for sub program General Ledger System Sub program: 50 SUBSISTENCE MAINTENANCE 5601 DEPRECIATION EXP BLDG. 5611 SPACE 5630 Page: Page 2 of 5 500 - CDBG-CVI 10/l/20-12/31/23 (Fund status: Active) 5910 INSURANCE Date: 11/23/2021 thru 12/31/2023 Period ending- October 2021 5361 MEDICAL INSURANCE,01C EXP Time'. 1:05:46 PM 5363 PENSION,OIC EXP 5364 ACCRUED PTO EXP $3, 060.00' 2,346.56 '403.48% $3.96 Bodge,t Expenditures Pct. Budget Expenditures Pct Annum budget Unexpended $10.00 $13-84 138-40% $130-00 $47.72 36.71% $400.00 $352.28 $15.00 $0.00 0.00% $195-00 $0.00 0.00% $600.00 $600.00 $64.00 $0.030 0.00% $832.00 $0.00 0.00% $2,500.00 $21500.00 $47.00 $0.00 0.00% $611.78 $0-00 000% $11864.78 $1,864.78 $512.00 $0.00 0.00% $6,656-00 $41559.80 68.51% $20,000.00 $15,440.20 $48.00 $36.72 76.50% $624.00 $667.82 107.02% $1,900.00 $1,232.18 $7.00 $0.00 0.00% $91.00 $0.00 0.00% $300-00 $300.00 $2,999-00 . ................ - $12,314.00 . ........... 410.60% $38,987.84 $33,284-95 85.37% $117,384-84 $841099.89 Sub program: 50 SUBSISTENCE MAINTENANCE 5601 DEPRECIATION EXP BLDG. 5611 SPACE 5630 UTILITIES 5640 BUILD. REPAIR/MAINT. 5910 INSURANCE 5912 LIABILITY INSURANCE Total for sub program 50 Total for program 62 ---_-> Program: 03 MICROENTRPRS 5311 SALARI , ES."WAGES, EXPEOW 5351 FICA, 0fG EXP 5352 L AND SHARE 25-80% $15.00 5353 STATE iX UbS) . _,�Qfc:EXP 5355 PAID FAMILY MEDICAL LEAVE 5360 DISABILITY OIC EXPENSE 5361 MEDICAL INSURANCE,01C EXP 5362 LIFE INSURANCE,01C EXP 5363 PENSION,OIC EXP 5364 ACCRUED PTO EXP $11.00 $8.98 81.64% $17.00 $6.43 37.82% $15-00 $3.87 25-80% $15.00 $9.32 62.13% $0.00 $0.00 0.00% $3.00 $3.96 132.00% _.._......^ ... $61.00 . ..... _­,­_­ ............ -432- 53.38% $0.00 j�, $24.00 $3, 060.00' 2,346.56 '403.48% $3.96 -A, $149.00 $145.04 $793-00 $32.56 4.11% $1,569.00 $0.00 0.00% $112.00 $0.00 0.00% $14.00 $0.00 0.00% $38.00 $0.00 0-00% $7.00 $0.00 0.00% $25.00 $0.00 0.00% $497.00 $0.00 0.00% $10.00 $0.00 0.00% $136.00 $0.00 0.00% $172.00 $0.00 0.00% $143-00 $8.98 6.28% $461-00 $452.02 $221.00 $6.43 2.91% $667.00 $660.57 $195-00 $3-87 1.98% $586.00 $582.13 $195-00 $9.32 4.78% $613-00 $603.68 $0.00 $0.00 0.00% $24.00 $24-00 $39-00 $3.96 10.15% $149.00 $145.04 $793-00 $32.56 4.11% $2,500.00 $27467.44 $397780.84 $33,317.51 83.75% $1191884.84 $861567.33 $20,397.02 $0.00 0.00% $611196.02 $61,196.02 $1,456.00 $0.00 0-00% $4,386.00 $4,386-00 $182.00 $0.00 0.00% $581-00 $581-00 $494.00 $0.00 0.00% $1,499.00 $1,499.00 $91.00 $0.00 0.00% $295.00 $295.00 $325.00 $0.00 0.00% $986.00 $986.00 $6,461-00 $0.00 0.00% $19,401-00 $19,401-00 $130.00 $0.00 0.00% $392.00 $392.00 $1,768.00 $0.00 0.00% $5,335-00 $5,335.00 $2,236-00 $0.00 0.00% $6,740.00 $6..740-00 General Ledger System OIC OF WASHINGTON .For User: INGRID FRANK Fund Expenditure report for." 500 - CDBG-CV1 10/l/20-12/31/23 (Fund status: Active) Report year: 10/112020 thru 12/31/2023 Period ending: October 2021 Account ------__- 5402 AUDIT COSTS 5500 TRAVEL 5618 CLIENT MORTGAGE PYMENT 5619 HOUSING ASST/RENT 5700 CONSUMABLES 5712 REPRODUCTION SUPPLIES 5800 EQUIPMENT 5910 INSURANCE 5912 LIABILITY INSURANCE 5945 ADVERTISING 5949 STAFF TRAINING 5959 SERVICES 5960 COMMUNICATION 5965 CLIENT TRAINING 5970 POSTAGE Total for sub program -----> Sub program: 50 MICRO MAINTENANCE 5601 DEPRECIATION EXP BLDG. 5611 SPACE 5630 UTILITIES 5640 BUILD. REPAIR/MAINT. 5910 INSURANCE 5912 LIABILITY INSURANCE Total for sub program 50 - - Total for program 63 -----> Program: 64 HOUSING 5311 SALARIES, AGES EXPENSE 5351 FICA,OIC ERCP Page: Page 3 of 5 Date: 1112312021 Time.: 1:05:47 PM ---------Monthly ------__- __..-.,...-------To Date---_-.._- Budget Expenditures .. _...... ..... ... Pct Budget Expenditures Pct Annual budget Unexpended $25.00 $0.030 0.00% $325.00 $0.00 0.00%Q $1,060.00 $1,000.00 $51.00 $0.00 0.00% $663.00 $171.92 25.93% $2,000.00 $17828.08 $51,00 $0.00 0.00% $663.00 $0.00 0.00% $21000.00 $21000.00 $13435.00 $0.40 0.00% $181655.00 $0.00 0.00% $56,000.00 $56,000.00 $102.00 $0.00 0.00% $1,326.00 $200.11 15.09% $4,000.00 $3,799.89 $64.00 $0.00 0.00% $832.00 $0.00 0.00% $2,500.00 $27500.00 $102.00 $0.00 0.00% $11326.00 $21083.41 157.12% $4,000.00 $1,916.59 $10.00 $0.00 0.00% $130.00 $03.00 0.00% $400.00 $400.00 $15.00 $0.003 0..00% $195.00 $0.00 0.00% $600-00 $604.00 $64.00 $0.00 0.0€3%a $832.00 $0.00 0.00% $2,500.00 $21500.00 $51.00 $0.00 01.00%a $663.00 $0.00 0.00% $2,000.00 $2,000.00 $51.00 $0.00 0.00% $663.00 $14,697.02 2216.75% $27000.00 ($12,697.02) $48.00 $0.00 0.00% $624.0€3 $0.00 0.06%0 $11900.00 $1,900.00 $51.00 $0.00 0.00% $663.00 $03.030 0.00% $21000.00 $21000.00 $7.00 $0.00 0.00% $91.00 $0.00 0.00% $300.00 $300.00 $4,707.00 $0.00 10.00% $617191.02 $17,152.46 28.03% $184,011.012 $166,858.56 $14.00 $0.00 0.00% $182.00 $0.00 0.00% $553.00 $553.00 $24.00 $0.00 0.00% $260.00 $0.00 0.00% $800.00 $800.00 $18.030 $0.030 0.00% $234.00 $+0.00 0.00% $7.03.00 $703.00 $18.00 $0.00 0.00% $234.00 $0.00 0.00% $736.003 $736.00 $0.00 $0.00 0.00% $0.40 $0.00 0.00% $28.00 $28.00 $4.00 IJ $52,00 $0.00 0.00% $180.00 $180.00 k7l' $74.00 $0.00 , 0.00% $962.00 $0.00 0.00% $3,00303.003 $31000.00 $4,781.00 $0.00 0.010% $62,153.02 $17,152.46 27.60% $1873011.02 $169,858.56 $1,648.00 $0.00 0.00% $21,424.74 $0.04 0.00% $64,294.74 $64,294.74 $118.00 $0.00 0.00% $1,534.00 $0.00 0.00% $4,608.00 $4,608.00 General Ledger System OIC OF WASHINGTON For User: INGRID FRANK Fuad Expenditure report for: 500 - CDBG-Cv1 1011120-12131123 (Fund status: Active) Report year: 10/112020 thru 1213112023 Period ending: October 2021 Account 5601 5352 LAND I,OIC SHARE 5353 STATE UCI(ES),OIC EXP 5355 PAID FAMILY MEDICAL LEAVE 5360 DISABILITY OIC EXPENSE 5361 MEDICAL INSURANCE,OIC EXP 5362 LIFE INSURANCE,OIC EXP 5363 PENSION,OIC EXP 5364 ACCRUED PTO EXP 5402 AUDIT COSTS 5411 CREDIT REPORTS 5500 TRAVEL 5618 CLIENT MORTGAGE PYMENT 5619 HOUSING ASST/RENT 5700 CONSUMABLES 5712 REPRODUCTION SUPPLIES 5800 EQUIPMENT 5910 INSURANCE 5912 LIABILITY INSURANCE 5945 ADVERTISING 5949 STAFF TRAINING 5960 COMMUNICATION 5970 POSTAGE Total for sub program -----, Sub program: 50 HOUSING MAINT 5601 DEPRECIATION EXP BLDG. 5611 SPACE 5630 UTILITIES 5640 BUILD. REPAIR/MAINT. 5910 INSURANCE Budget $15.00 $40.00 $7.00 $28.00 $522.00 $10.00 $143.00 $181.00 $7.00 $0.00 $51.00 $153.00 $1,128.00 $89.030 $64.00 $102.00 $10.00 $15-00 $89.00 $5'1.00 $48.00 $12.00 $4,529.00 $76.55 1.69% Page: Page 4 of 5 Date: 1112312021 Time: 1:05:48 PM ---To Date ---�-- Expenditures Pct $0.00 0.00% $0.00 0.00% $0.00 0.00% $0.00 0.00% $10.00 0.00% $0.00 0.00% $0.00 0.00% $0.00 0.030% $0.00 0.00% $0.00 0.00% $0.00 0.00% $0.00 0.00% $0.030 0.00% $0.030 0.00% $1.67 2.61% $0.00 0.00% $0.00 0.00% $0.00 0.00% $0.00 0.00% $0.00 0.00% $71.59 149.15% $3.29 27.42% $76.55 1.69% Page: Page 4 of 5 Date: 1112312021 Time: 1:05:48 PM Unexpended $611.00 $1,575.00 $310.00 $1,036.003 $20,384.00 $412.00 $5,605.00 $7,082.00 $300.00 ($348.00) $1,797.28 {$1,573.46} $1,925.55 $3,406.58 $2,455.36 $1,431.58 $400.00 $60)0.00 ($2,180.00) $1,800.00 $1,538.77 $392.38 $117,863.78 $14.00 ---To Date ---�-- 0.00% Budget Budget Expenditures Pct Annual budget $195.00 $0.00 0.00% $611.00 $520.00 $03.00 0.00% $1,575.00 $91.00 $0.00 0.00% $310.00 $338.00 $0.00 0.00% $11030.00 $6,786.00 $0.00 0.00% $207384.00 $130.00 $0.00 0.00% $412.00 $1,859.00 $0.00 0.00% $5,605.00 $21353.00 $0.00 0.00% $7,082.00 $01.030 $0.00 0.00% $300.00 $0.00 $348.003 0.00% $03.00 $653.00 $202.72 303.58% $2,000.00 $1,989.00 $7,573.46 380.77% $610003.00 $14,664.00 $42,074.45 286.92% $441000.00 $11157.030 $93.42 8.07% $3,500.00 $832.00 $44.64 5.37% $2,500.00 $1,326.00 $2,568.42 193.70% $4,000.00 $130.00 $0.00 0.00% $4003.00 $195.00 $0.00 0.00% $600.00 $1,157.00 $51680.00 490.92% $3,500.00 $663.00 $200.00 30.17% $2,000.00 $624.00 $361.23 57.89% $1,900.00 $156.00 $107.62 68.99% $500.00 $58,877.74 $591253.96 100.64% $177,117.74 Unexpended $611.00 $1,575.00 $310.00 $1,036.003 $20,384.00 $412.00 $5,605.00 $7,082.00 $300.00 ($348.00) $1,797.28 {$1,573.46} $1,925.55 $3,406.58 $2,455.36 $1,431.58 $400.00 $60)0.00 ($2,180.00) $1,800.00 $1,538.77 $392.38 $117,863.78 $14.00 $0.00 0.00% $182.00 $0.00 0.00% $553.00 $553.00 $2000 $0.00 0.00% $260.00 $0.00 0.00% $800.00 $800.00 $18.00 $0.00 0.00% $234.00 $0.00 0.00% $703.00 $703.00 $18.00 $0.00 03.00% $234.00 $0.00 0.00% $736.00 $736.00 $0.00 $0.00 0.00% $0.00 $0.003 0.00% $28.00 $28.00 OIC OF' ASHINGTON For User.- INGRID FRANK Fund Expenditure report for: 500 - CDBG-CV1 10/1/20-12/31123 (Fund status'. Active) Report year: 10/1/2020 thru 12/31/2023 Period ending: October 2021 Account 5912 LIABILITY INSURANCE Total for sub program 50 Total for program 64 --> Total for department 030 ---> Fund Totals ----Mont1z1y--- --To Date— Budget Expenditures Pct $4.00 $0.00 0.00% $74.00 nct $0.00 0.00% $4,603.00 L U_ 4 1.66% $3,000.00 $31000-00 $59,839.74 $123444.00 $12,423.11 99.83% $141574.00 Page: Page 5 of 5 Date: 11/23/2021 Time: 1:05:48 PM $131570.65 -- 93.12% $1891464.00 $117,973.53 62.27% $570,117.00 $452,143.47 Lj --To Date— Budget Expenditures Pct Annual budget Unexpended $52.00 $0.00 0.00% $180.00 $180.00 $962.00 $0,00 0.00% $3,000.00 $31000-00 $59,839.74 $59,253-96 99-02% $180,117-74 $120,863.78 $161,773.60 $1097723.93 67.83% $4871013.60 $377y289-67 $131570.65 -- 93.12% $1891464.00 $117,973.53 62.27% $570,117.00 $452,143.47 Lj Ara� 'WAiHIN"I'ONTTE 5,400.00 AGENCY NUMBER IDIS PROJECT NUMBER COMMERCE CONTRACT NUMBER DEPARTMENT OF COMMERCE 05Q PS -Subsistence Payments/05X Housing Assistance $ 3579083.00 $ A19 VOUCHER DISTRIBUTION 1030 107 20-6221 C-111 AGENCY NAME INSTRUCTION TO VENDOR OR CLAIMANT. DEPARTMENT OF COMMERCE Submit this form to claim payment for materials, merchandise or services. ATTN: CDBG-CV PO BOX 42525 Vendor's Certificate: I hereby certify under perjury that the items and totals listed herein are OLYMPIA, WA 98504-2525 proper charges for materials, merchandise or services furnished to the State of Washinaton. 21 A General Admin $ 5,400.00 $ - $ 5,400.00 05Q PS -Subsistence Payments/05X Housing Assistance $ 3579083.00 $ 86,013.86 $ 139570.65 $ 2579498.49 $ - 18C Microenterprise Assistance $ 2135035.00 $ 185389.02 $ - $ 1945645.98 l ,,457,54447To$PRe.6 . M 'SUB TRANS I O. SUB CODE D MASTER INDEX ' . SUB OBJ OBJ GL ACCT SUBSID AMOUNT -INVOICE NUMBER CI 622CO320 NZ No= SIGNATURE OF ACCOUNTING PREPARER FOR PAYMENT DATE WARRANT TOTAL CMS Invoice ID: ACCOUNTING APPROVAL FOR PAYMENT DATE