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VOUCHER AND PRACTICE CERTIFICATION SUMMARY FORM <br />A. IPAYEE INFORMATION Check if name or address change I PRACTICE INFORMATION <br />Name LD. Number <br />Citv of Roseville: Aladdin Street Project #- C10-89 <br />.�C , %,O= Buis of Request Type of Request Tow Cost of Project <br />lnforrrwtlon Instalart1w ❑Rsinsialiati.. Pau M-Lm $75,335.95 <br />R11 MEM QUANTITY ijNrr OWr PRICE COST <br />See Attached <br />(ansch sed.."wraf afteoft as nacessovy) TOTAL <br />R: ReceltAfinvviced Neon L Ift4dod CorftImMon <br />I certify that thin is anaccurate and " surnav%'t of fie actual costs and wantities, ofmatarim, tabu, mid eopmeirt used on the above pitisa In erica wharethe recelpts indudad 42M not Mad On the <br />project, I have �xmvcted them amwdrKk. <br />IPAYV--NT WORMATM LP= S! Mn Date <br />atUre) () <br />TOTAL COST OF PRACTICE $75,335.95 <br />PROGRAM COST -SHE <br />PAYMENT $27,000.00 ffi— box a] (a) Total of Prewous Payrnerris <br />Cidw Funding Sources (measo idoruN aww) (b) Cost-Sham Payment Request $27,OWOO <br />$ COST-SHARE PROGRAM f(s) + (b) "Mot G=eW 75% of (CR <br />$ (C) Total Cwt Aistwoved $75,335.96 <br />$ (d) Other Putft Funds t % Is <br />$ (a) DsW!ct Share E36% $27,000.00 <br />I�te IIKL I KF-Pr--21MIA YFIF With TAA WI$TF-ATFW SION-Off DEW.111ATED MYCD REP. 1CONSERVA111101111 DISTRICT BOARD CHAIRPERSON fo-W 11W9 I <br />BWSR Voucher Aladdin Sheet <br />