Spreadsheet: 0958f1de-3cd0-47cc-91ad-961c5bc8dc4f
Sheet: Sheet1

Unnamed: 0 | DOLA ENERGY and MINERAL IMPACT ASSISTANCE PROGRAM:                Reimbursement Request and Quarterly Project Progress Report Form | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10
 | Grantee & Project Name: | Big County - Water System Improvements |  |  |  |  | EIAF# | 1234
 | Check Applicable Purpose:
 | Quarterly Project Progress Report Only |  |  | Reimbursement & Quarterly Report |  |  | X | Reimbursement Only
 | Section I:     QUARTERLY EXPENDITURE SUMMARY
 | Instructions: Check the appropriate box for the calendar year quarter.  Enter only the amount of State Impact Funds expended during this Quarter.
 | Calendar Year 2011 | p Jan-Mar | p Apr-Jun | p July-Sept | X Oct-Dec | Amount of Impact Funds Expended in Quarter $__140,000.00________________
 | Section II:      CURRENT REQUEST |  | Pay Period Covered by this Request: |  |  | 2011-01-01 00:00:00 | through | 2011-03-31 00:00:00
 | Reimbursement Request Number: | 1 | PLEASE ENTER "X" IF THIS IS YOUR FINAL REQUEST:
 | EIAF                                       Contract Budget Line Item,                        Name of Construction Contractor, Vendor, Professional Firm, etc. | Invoice                             Number                   &                        Date | Grantee Check Number | Date                              of                                 Grantee                            Check | Total                                 Invoice                        Amount | Purpose for Funds Requested (#1-8, See Column B - Page 2) | Expense Amount to be Paid with State Impact Grant and/or Loan Funds | Expense Amount to be Paid with Grantee Cash | Expense Amount to be Paid with Other Cash (if listed in state contract) | Identify Source of Other Cash (if not EIAF or Grantee Cash)
1 | ABC Engineering | #4321/10-5-10 | 7654 | 2010-10-20 00:00:00 | 40000 | 2 | 20000 | 20000
2 | Big Time Construction | #1/11-1-10 | 40497 | 2010-11-15 00:00:00 | 100000 | 1 | 50000 | 50000
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
 | TOTALS: |  |  |  | 140000 |  | 70000 | 70000 | 0
 | Amount of Request: |  |  |  |  |  | 70000
 | Section III:         PROJECT EXPENSE SUMMARY (Total to Date)
 |  | A | B | C | D | E | F
 | EIAF                                                          Contract Budget Expense                            Item Description                                 (Per State Contract Scope of Services) | State Contract Budget Line Item Amount (per State Contract Scope of Services) | Total State Impact Funds Expended To Date, including this Pay Request | Total Grantee Cash and Other Funds Expended To Date, including this Pay Period | Total In-Kind Funds Expended To Date,including this Pay Period | Total  Expended       (B plus C plus D) | Budgeted Funds Remaining       (A minus E)
1 | Construction/Improvements to Public Facility | 900000 | 50000 | 50000 |  | 100000 | 800000
2 | Engineering | 100000 | 20000 | 20000 |  | 40000 | 60000
3 |  |  |  |  |  |  | 0
4 |  |  |  |  |  |  | 0
5 |  |  |  |  |  | 0 | 0
6 |  |  |  |  |  | 0 | 0
7 |  |  |  |  |  | 0 | 0
8 |  |  |  |  |  | 0 | 0
 | TOTALS: | 1000000 | 70000 | 70000 | 0 | 140000 | 860000 |  |  | 0
 | Section IV:         QUARTERLY PROJECT PROGRESS REPORT
 | Please report project activities undertaken or completed during the above indicated Quarter.  Include percentage of project completed to date.
 | Preliminary engineering complete.  Final invoices not in yet.  This allowed for initial site work to commence.  Project is 5% complete at this time.
 | I certify to the best of my knowledge the data in this report is correct and all expenditures were made in accordance with the grant contract agreements.
 | [NAME] |  |  |  |  | 2011-04-01 00:00:00
 | Signature (Elected Official or Responsible Administrator) |  |  |  |  | Date
 | For DOLA Staff Only |  |  | Check Appropriate Box | Date of Review or Site Visit |  |  | Reviewer's Initials
 | Documentation Submitted by Grantee
 | Documentation Reviewed On-Site