Grant Recipient
(Required)
Project Title (AS LISTED ON CONTRACT)
(Required)
Project Number (FROM CONTRACT)
(Required)
PXX-XX-XXXX
Funding Source
(Required)
State
Federal (RTP)
Unsure
Project Manager
(Required)
First
Last
Project Manager Email
(Required)
Project Manager Phone Number
(Required)
Is this form being submitted by someone other than the project manager?
(Required)
Yes
No
Secondary Contact Information
Name
First
Last
Phone
Email
Project Connection
Please provide your title and organization.
Reimbursement Request
Award Amount
(Required)
*Your contract award amount, not the Total Project Value (TPV)
Total Previously Requested ($)
(Required)
*Do not include current requested amount in the above total
Dates of Service
(Required)
From XX/XX/XXXX to XX/XX/XXXX. Must be within contract begin and end dates.
Brief description of project accomplishments associated with this request:
(Required)
Reimbursement Request Amount
(Required)
Minimum Match Due for this Request
Match Submitted
(Required)
Total Project Value
Comments:
Please use this section to provide any comments you might have regarding this reimbursement.
Required Documents
Excel Workbook
(Required)
Drop files here or
Select files
Max. file size: 20 MB.
Invoice(s)
(Required)
Please use this entry to submit any and all invoices or receipts required for this reimbursement.
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Select files
Max. file size: 20 MB.
Proof of Payment(s)
(Required)
Please use this entry to submit all proof of payments required with this reimbursement (this can include void checks, bank statements, EFT, paystubs and payroll reports).
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Select files
Max. file size: 20 MB.
Other documents:
Please use this entry to submit any other supporting documents.
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Select files
Max. file size: 20 MB.
Certification of Accuracy
(Required)
I hereby certify that all information provided above is true, complete, and accurate to the best of my knowledge.