Laserfiche WebLink
i <br /> M= <br /> Encumbrance Worksheet 5/30/14 i <br /> Vendor Name: Vendor Number: ` <br /> City of Centerville <br /> Address: Federal Employer I.D. or Social Security#: <br /> 1880 Main Street, Centerville, MN 55038 41-1267014 <br /> Requestor's Name/Employee ID#: (for SWIFT entry) MN Tax I.D.#(if applicable): <br /> Cristina Covalschi 01135389 <br /> 2015 Total amount of Original Agreement: $10,000 <br /> Starting Fiscal Year: (include initial request and all <br /> previous amendment totals) <br /> Start Date: 51112015 $ ' <br /> Total Amount of this Amendment: <br /> Initial End Date: 04/30/2016 <br /> Revised End Date: <br /> Please Check ONE OPTION for amendments: Time Only Money Only Time and Money I <br /> I <br /> ACCOUNTING INFORMATION <br /> Fiscal Year 2015 <br /> I <br /> Fund Dept ID Appr ID Project ID , Activity ID Amount <br /> 2302 H123 2139 H12555P $ 10,000 <br /> H123 $ <br /> H123 $ <br /> LCFDA#(if Federal$) <br /> i <br /> Fiscal Year 201 <br /> Fund Dept ID Appr ID Project ID Activity ID Amount <br /> H123 $ <br /> H123 $ <br /> H123 $ <br /> 1 <br /> Fiscal Year 201 <br /> Fund Dept ID Appr ID Project ID Activity ID Amount <br /> H123 $ <br /> H123 $ <br /> H123 $ i <br /> 1 <br /> FINANCIAL MANAGEMENT ONLY <br /> Authorized Signature for Date <br /> Encumbrance <br /> Contract Number 6 Origin Code <br /> Purchase Order Number Source Type <br /> Category CodeAccount ID <br /> 0 716— i0 <br /> NOTE: This page of the Agreement Contract contains conflAndal information and should not be reproduced or distributed externally without written <br /> permission from the Vendor. Intemal circulation of this page should only be to individualsroftes signing this Agreement Contract and those that require <br /> access to the tax identification number. <br /> I <br /> 34 <br />