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GRANT COUNTY
COMMISSIONERS AGENDA MEETING REQUEST FORM
(Must be submitted to the Clerk of the Board by 12:00pm on Thursday)
REQUESTING DEPARTMENT: BOCC
REQUEST SUBMITTED BY: Karrie Stockton
CONTACT PERSON ATTENDING ROUNDTABLE: Karrie Stockton
CONFIDENTIAL INFORMATION: DYES Fm NO
DATE. 6/1 0/Z024
PHONE:2937
N
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'W UGGE'VTED:1►1f�''"� �` `. ;C0. S, ei
-.. VVhc 'It1�`hat .,;'llU'hn ,�1`I'h Trrn
Reimbursement req est from theTown- of Coulee City on the Strategic
- ,91 a s
Infrastructure (SIP) Grant #SIP 2022-03 in the amount of $40,000.00.
This is the total'a��proved award amount.
If necessary, was this document reviewed by accounting? ❑ YES ❑ NO 0 N/A
If necessary, was this document reviewed by legal? F.
YES ❑ NO C_1 N/A
DATE OF ACTION: t � 647 DEFERRED OR CONTINUED TO:
APPROVE: DENIED ABSTAIN
D1:
D2:
D3:
4/23/24
GRANT COUNTY
�WTRATEGIC INFRASTRUCTURE PROGRAM
PROJECT CERTIFICATION
This form must be signed and returned with an invoice, for the approved funding,
LY,
before reimbursement can be approved by Grant County,
SIP Project Proposal Number: IPO -03
SIP Funding Recipent Town of Coulee City
SIP P ject . Dese tion Pi
TQJ C .-
I i t De,
utli y sign and an
4 the -undersigned, do hereby certify under penal tv of pe
Jury, that the materiala�
hve
s
been fuillisbed, the services rendered, and/or the. labor perfori-ned as described n the
i
project proposal for the above-refere*nced SIP Prof ect and that I am authorized to
authenticate and certify totbilaim
I also cortify that tbis claim isjust and due and is
an unpaid obliaation aga*
in8t Grant County,
Further, accordina to the SIP Project Funding, Policies, I -attest that at the next audit of my
entity, this project shall be called to the attention of the Washington State Auditor's
Office and an emphasisaudit 11 be requeste o assure
au wi d t that these funds were expended
toward the prof ect and according to the 'Intents
of thepropoal.
-
Signa r
.Printed Namje
t, 5A2:��gk
Date Signed
Title
Printeditle
0
Completed, signed original certification and inv*oice are to be- mailed to.
AdministrativeSe IrVIces Coordinator, PO Box 37 Ephrata, WA 98823
ATTACHMENT 4
SIP - Park Utility Plan
Project: 2022-03
SIP Approved Funds
Engineering
$401000.00
SIP
100% 1
Coulee City
0%
SIP Funds Available
$40,000.00
$0.00
Billed TD: $ 40, 000.00 $ -
SIP Balance: $0.00 $0.00
Reimbursed TD: $ -
Check
Reimbursement
Date
Vendor
Invoice No.
Total
No
Submitted
Recel ted
Amount
2/22/2023
Gray and Osborne
23802.00-1
15193
$
471.70
$
471.70
3/8/2023
Gray and Osborne
23802.00-2
15207
$
21186.19
$
21186.19
4/12/2023
Gray and Osborne
23802.00-3
15232
$
61905.57
$
61905.57
5/10/2023
Gray and Osborne
23802.00-4
15278
$
11707.09
$
11707.09
5/22/2023
Gray and Osborne
23802.00-5
15300
$
31097.48
$
31097.48
6/20/2023
Gray and Osborne
23802.00-6
15321
$
377.52
$
377.52
9/27/2023
Gray and Osborne
23802.00-7
15406
$
61169.62
$
61169.62
10/25/2023
Gray and Osborne
23802.00-8
15421
$
10,674.44
$
101674.44
11/15/2023
Gray and Osborne
23802.00-9
15446
$
71284.89
$
71284.89
1/5/2024
Gray and Osborne
23802.00-10
15522
$
17047.87
$
11047.87
5/23/2024
Gray and Osborne
23802.00-11
15644
$
77.63
$
77.63
$
-
Request Submitted
$
40,000.00
Billed TD: $ 40, 000.00 $ -
SIP Balance: $0.00 $0.00
Reimbursed TD: $ -