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CDPHE Nonpoint Source Program Cost Reimbursement Invoice
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To:From:Project Title:
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CO Dept. of Public Health & Environment Nonpoint Source Program Attn: Project Coordinator Name 4300 Cherry Creek Drive South Denver, CO 80246 John Doe Agency/Entity Address Line 1 Address Line 2
Contract Number:
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Federal Tax Id. #:
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Invoice Request #:
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Expenditures Time Period:
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Amount of this Request:
$0.00
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* Funds reported in these columns cannot be federal funds or used to match other federal programs.
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Task Description
Product/Deliverable
NPS FundsCurrent ExpenditurePrevious Cumulative ExpenditureCurrent Cumulative ExpenditureRemaining NPS FundsWQIF FundsWQIF Current ExpenditureWQIF Previous Cumulative ExpenditureWQIF Current Cumulative ExpenditureRemaining WQIF Funds (to be spent by 6/30/2023)Required Match (Cash+In-Kind)Current Reported Match (Cash+In-Kind) *Previous Cumulative Reported Match* (Cash+In-Kind)Current Cumulative Match*Remaining Match*Total Cost (Including Match + WQIF)
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Task 1
BMP DesignFinal BMP designs$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00
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Task 2
BMP ImplementationAt least 2 constructed BMPs that address NPS sediment loading$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00
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Task 3
Education & OutreachHandouts, print materials, web-based outreach materials$0.00 $0.00$0.00$0.00$0.00$0.00$0.00 $0.00$0.00$0.00
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Task 4
Monitoring & EvaluationApproved SAP, data uploaded to WQX/WQ Portal$0.00 $0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00
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Task 5
Reporting & Financial ManagementProgress, Semi-annual & Final reports$0.00 $0.00$0.00$0.00$0.00$0.00$0.00 $0.00$0.00$0.00
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Totals$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00$0.00
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Version 6 7/2021
****Please do type in the red or grey cells
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To be Signed by Contractor/Vendor
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I/We affirm the claimed expenses comply with the budget provisions of the contract and are reasonable and necessary, that all relevant progress or other reports have been timely filed, and all contract milestones and/or tasks related to the billing period have been achieved.
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Signature & TitleDate
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To be Signed by CDPHE Program Director or Delegate
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I affirm that I or my staff have reviewed the contractor's invoice and supporting documentation (as required), progress reports and other communications with the contractor, and believe to the best of my knowledge, that the contractor is in compliance with all contract provisions.
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Signature & TitleDate
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To be Signed by CDPHE Fiscal Officer or Delegate
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I certify that the claimed expenses have been reviewed by me for compliance with the requirements of the funding source and the State of Colorado Fiscal Rules, and are charged to the appropriate funding source.
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Signature & TitleDate
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