Agency’s Certification and Reimbursement Request Form
I. Agency’s Certification and Reimbursement Request
The information presented on this form is true and complete to the best of my knowledge;
All programs and services have been executed in accordance with the terms and requirements of the contract;
All expenses for which payment is being requested herein were incurred by the above-referenced program(s);
All approved Board minutes and agendas have been received by the Community Development Department;
A signed and dated Client Report, Narrative Report, and Fund-Raising Report have been received by the Community
Development Department;
All sup
porting documentation to substantiate this request has been received by the Community Development
Department.
The agency is in full compliance with the terms and conditions of the above referenced contract.
I hereby request reimbursement for approved program expenses to date in the amount of $ __________.
____________________________________________________ _____________________
Signature of Agency Contact Date
II. Monitor’s Certification
I have reviewed the documents submitted for the _____ quarter by the above-referenced agency and agree that all services
and expenditures have been satisfactorily completed in accordance with all applicable requirements and terms of the above
referenced contract number.
I hereby approve payment to the ag
ency in the amount of $________.
____________________________________________________ ______________________
Signature of Monitor Date
III. Community Development Manager’s Certification
I hereby approve payment to the agency in the amount of $_________.
____________________________________________________ _______________________
Signature of Community Services Director Date
(If applicable)
