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EWOII83T 2 - MONTHLY PATREWEST <br />K=AS COUNW DEPARTMENT OF PUBUC WORKS 7a1; {509)992 7523 <br />411 to. RWeYRme%SuHs OL Ebmbur& WA 911926 Fuc (5119) 9EZ-7E63 <br />H -UM Polb0a Fad1hinlF mukCopy of FwBnS Request Tor payment 20156 PAGE 1 <br />PURM FACILITIES FUNDING REQUEST FOR PAYMENT <br />RegrrestlrrE Ap.ray: <br />lddterou <br />act Naw. <br />_ � QbY/at�7+P <br />Period Caaered <br />Fadaral 0 Na <br />4IPhanaif <br />� yes No <br />COWDISCRIPTIDNA <br />Roomstiur Peymprt mtgtbeacaemparlied Ly <br />hnakewpks. <br />0 <br />Eayae9a Thin Peried drrpuryas PrartatrdT Repassed <br />A46 <br />Eapaesas Ta Oats <br />CAM) <br />C <br />Required Matching Funds <br />(2096] <br />IM.'" <br />A+6 -t <br />ttomftaahlalre <br />IM) <br />rks arrd 021MMR e <br />aolks b <br />Se vkw A Cham is <br />Other e <br />Al (esb*c+dj <br />Tans F-p-ftre thisveriad Toot prrar period b enre <br />Total Eupeme to Date <br />Tedal hweh Iodate <br />Teti Reimbursable ansa <br />rrFrFA%COU? VU TCN1Y, <br />AWAP.D <br />LES 7REa1WS PAYMENTS <br />LESS PREYIOUE PAVUENTS <br />;REIStAfPItNG lNAFIEE <br />6TRL PAYMEM REQUESTTItl6 PEMOD��� <br />I WMIT that the costs shown an thh: vuudtel' ate tnw and wrrect; the ameuut da:med Is due and payable fmm the KSHtas CwnW Public Feet" Fond urWe"pplkable bw% rulq, regulations and procedure; m claim <br />has hewn pennted to or pa rd: made Tar the amoum for Whldr Is clatrnd herein; claim does mt axwool thea P=d altowtiaq Tar ffiN ngad. and I am aethorkW tP$IF tar c%Imant <br />Granas; <br />Ix <br />Date; <br />1OTTR.6 G9111ETY tJ6E pNI.Y <br />Mcluaas tar Paymeas Q1^&sd Be <br />ftvMp0,Udhauaf By <br />Oahe <br />H -UM Polb0a Fad1hinlF mukCopy of FwBnS Request Tor payment 20156 PAGE 1 <br />