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SUBCONTRACTOR'S INVOICE FINAL Invoice Number: 13 <br /> 1. Subcontractor's Name (Agency) Address (Number and Street) <br /> Hawaii County Office of Aging 101 Aupuni Street, Room 342 <br /> 2. Clty or Town Funds Requested For: <br /> Hilo [ ]Initial [ ]Periodic [ X ] Reim- [ ]Final <br /> 6. Contract Number: Advance Advance bursement Invoice <br /> PY03-SCSEP-H-HCOA <br /> 8. Funds Requested For: Senior Community Service Employment Program <br /> 9. Contract Period: 10. Report Period: <br /> From: To: From: To: <br /> July 1, 2003 June 30, 2004 1-Jun-04 30-Jun-04 <br /> 11. CASH TRANSACTION DATA <br /> a. Total cash received to date . $271,977.97 <br /> b. Total disbursements to date from July 1, 2003 to June 30, 2004 $281,828.00 <br /> c. Cash on hand/deposit (9,850.03) <br /> d. Cash requested but not received <br /> e. Cash on hand/deposit & cash requested but not received . (9,850.03) <br /> f. Estimated disbursements from to N/A <br /> g. Amount of cash advance requested herewith. $9,850.03 <br /> 12. EXPENDITURE DATA <br /> Total Accrued expenditure to date. $281,828.00 <br /> (From Expenditure Register, page 2) <br /> 13. CONTRACTOR'S CERTIFICATION - I certify that the cost incurred are taken from the books <br /> of account and that such costs are valid and consistent with the terms of agreement. <br /> <br /> Authorized Subcontractor Signature and Title Date Signed <br /> <br /> Alan Parker, Executive on Aging <br /> G1~TAAbMIIVISTRATII~N U8E Q.IVLY <br /> Recommendation Appropriation Number <br /> Amount to be paid <br /> Signature Date <br /> <br />