HomeMy WebLinkAboutGAX form for Midpoint Catalyst Project - 7/13/2020 STATE OF IOWA GAX
BUDGETFY General Accounting Expenditure DOCUMENT
DATE ACCTG PERIOD(mm/yy) NUMBER
1/13/2022
VENDOR CODE AGENCY NAME
42-6005327
VENDOR NAME AND ADDRESS BILL TO ADDRESS(ORDERING AGENCY) SHIP TO ADDRESS
City of Waterloo Iowa Economic Development Authority
715 Mulberry Street 1963 Bell Avenue,Suite 200
Waterloo Iowa 50703 Des Moines, IA 50315
TERMS FOB ORDER APPROVED BY GOODS RECEIVED/SERVICES
PERFORMED
DATE INITIALS
VENDOR'S INVOICE NUMBER
QUANTITY T T
Line item Contract budget* Expenditures
Since Last Previous Cumulative
Report(1) Total(2) Expenditures(1+2)
Project Expenses Eligible for Reimbursement
Grant Contract and approved budget in IowaGrants.gov Up to $60,643.86 $ 0 $60,643.86
$100,000
Project Name:West 3rd Street Corner Market
Project Address: 1427-1429 W 3rd Street,Waterloo
4—
Funds Requested $ 60,643.86
CONTRACT NUMBER: 20-CTBF-028 Less: Funds Requested to Date $0
DRAW# 1 NET REQUEST $ 60,643.86
CLAIMANT'S CERTIFICATION AGENCY CERTIFICATION
I CERTIFY THAT THE ITEMS FOR WHICH PAYMENT IS CLAIMED WERE FURNISHED FOR STATE I CERTIFY THAT THE ABOVE EXPENSES WERE INCURRED AND THE AMOUNTS
BUSINESS UNDER THE AUTHORITY OF THE LAW AND THAT THE CHARGES ARE REASONABLE, ARE CORRECT AND SHOULD BE PAID FROM THE FUNDS APPROPRIATED BY:
PROPER,AND CORRECT,AND NO PART OF THIS CLAIM HAS BEEN PAID. CODE OR CHAPTER SECTION(S)
DATE: 1/13/2022 TITLE: Mayor Quentin Hart
CLAIMANT'S SIGNATURE: Authorized Official for Grantee-i.e.City(Mayor)or MSI Program(Board Pres.) AUTHORIZED SIGNATURE
Gzi211-kll He_r4
THE FOLLOWING FIELDS ARE FOR STATE ACCOUNTING USE ONLY
DOC TYPE DOC NUMBER DOC DATE ACCTG PRD BUDGET ACTION PO SHIP GAX INT INT SELLER INT SELLER
(GAX) FY NEW/MOD INSTR TYPE IND FUND AGCY
GAX
VENDOR CODE ADDR F/A INDICATOR EFT IND TEXT-po's only(Y/N) TEXT(po's only)
42-6005327 OVERRIDE N
REF DOC TYPE REF DOC NUMBER REF DOC LINE COM LN VEND INVOICE# COMMODITY CODE GS CONTRACT
LINE FUND AGCY ORG SUB ACTV FUNC OBJT SUB JOB NUMBER REP CAT QUANTITY/ I/D DESCRIPTION AMOUNT I/D
ORG OBJT UNITS
01
02
DOCUMENT TOTAL $
GAX WARRANT # AUDITED BY PAID DATE