HomeMy WebLinkAboutGrant Related - BOCC (003)GRANT COUNTY
COMMISSIONERS AGENDA MEETING REQUEST FORM
(Must be submitted to the Clerk of the Board by 12:00pm on Thursday)
BOCC
10/19/2023
REQUESTING DEPARTMENT: DATE-
Janice Flynn
Ext 2937
REQUEST SUBMITTED BY: PHONE:
Janice Flynn
CONTACT PERSON ATTENDING MEETING:
CONFIDENTIAL INFORMATION: F-IYES ANO
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Reimbursement request for Strategic Infrastructure Program (SIP) Project No
2023-01 GC Hospital #4, McKay Healthcare, Phase 1 Architecture and
Engineering Site Plan in the amount of $455.28.
APPROVED lVQ
ODENIED
EITABLED/DEFERRED/NO ACTION TAKEN:
OCONTINUED TO DATE:
E]OTHER
DATE OF ACTION: �) NA 3✓
1 1
GRANT COUNTY
STRATEGIC INFRASTRUCTURE PROGRAM
PR(]JECT CERTIFICATION
This form must be signed and returned, with an invoice, for the approved funding,
before reimbursement can be approved by Grant County.
SIP Project Proposal Number: SIP2023-01
SIP Funding Recipient McKay Hospital & Rebab
SIP Project Description Phase 1 Architecture and Engineering Site Plan
1, the undersigned, do hereby certify under -penalty of perjury, that the materials have
been furnished, the services rendered, and/or the labor performed as described in the
project proposal for the above -referenced SIP Project and that I am authorized to
authenticate and certify to this claim. I also certify that this claim of $455.28 is just and
due and is an unpaid obligation against Grant County,
Further, according 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 emphasis audit will be requested to assure that these funds were expended
0
toward the prod and accordinp, to the intent of the proposal.
r0J -0-1
Signature
Victor Odiakosa
Printed Name
.-.0%
Da. & Signed
Administrator/Superintendent
Title
Admim"strator/Superintendent.
Printed Title
Completed, signed original certification and invoice are to be mailed to:
Administrative Services Coordinator, PO Box 37, Ephrata, WA 98823
Reimbursement# I in the amount of $455428
ATTACHMENT 4
575 Stewart Title Company 08/24/2023 93178
Invoice Number Invoice Date Description Gross Amount Discount Taken Net Amount Palid
710061 08/24/2023 Admin - PS - SIP2a!b
8 $0.00r—.. $455.2�]
Stewart Title Company
RECEIVED AUG 24 2023
McKay Healthcare
PO Box 819
Soap Lake, WA 98851
Remit to:
Stewart Title Company
117 E 4th Ave
Moses Lake, WA 98837
Invoice
Date: 08116/2023
Number: 710061
File Number
Transactee Client's FUG 9
Class/Descripflon Memo
Amount
2090473
Hospital Mtrict #4
RIF
Title: Owner's Coverage
$420.00
2090473
Hospital District #4
Title.- Premium Tax
$35,28
Total $456.28
Total Due
0
000
Uth An
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Vendor
Bars Code Name
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