Request for Payment
SECTION 1: PROJECT & AGENCY INFORMATIONCITY/COUNTY FORMTEXT ?????CONTACT NAME FORMTEXT ?????ADDRESS FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ?????ZIP FORMTEXT ?????EMAIL FORMTEXT ?????PHONE FORMTEXT ?????PROJECT NAME (from Agreement header) FORMTEXT ?????SECTION 2: BILLING INFORMATION (Attach documentation of all costs incurred. See Page 2, Section 4.)REQUEST DATE FORMTEXT ?????SERVICE FROM (MM/DD/YY) FORMTEXT ?????SERVICE TO (MM/DD/YY) FORMTEXT ?????PAYMENT REQUEST # (1, 2, 3, etc.) FORMTEXT ????? Is this a final request for payment? FORMCHECKBOX Yes FORMCHECKBOX NoAGREEMENT AMOUNT FORMTEXT ?????AMOUNT PAID BY KYTC TO DATE FORMTEXT ?????CURRENT REQUEST AMOUNT FORMTEXT ?????SECTION 3: AGENCY CERTIFICATIONI hereby certify that this is a true statement of costs incurred by our agency on the subject project and all work was accomplished in accordance with the agreement we signed with the Kentucky Transportation Cabinet.NAME FORMTEXT ?????TITLE FORMTEXT ?????SIGNATUREDATECOUNTY JUDGE EXECUTIVE (MAYOR for City) SIGNATUREDATEFOR DEPARTMENTAL USE ONLY AGREEMENT DATE FORMTEXT ????? AGREEMENT AMOUNT FORMTEXT ????? PROGRAM FORMTEXT ????? AMOUNT PAID BY KYTC TO DATE FORMTEXT ????? PROJECT AUTHORIZATION FORMTEXT ????? AVAILABLE FUNDS FORMTEXT ????? TOTAL COST OF PROJECT (OR CURRENT PORTION) FORMTEXT ????? PAYMENT REQUEST RECEIVED FORMTEXT ????? 20% AGENCY RESPONSIBILITY (IF APPLICABLE) FORMTEXT ????? REVIEWED BY FORMTEXT ????? AMOUNT TO BE PAID BY KYTC FORMTEXT ?????SECTION 4: DOCUMENTATION OF COSTS INCURRED (Use this page multiple times if needed.)AGREEMENT ITEMATTACHED INVOICE # (if applicable)1234 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????CHECK #COSTExample: John’s Rock Company12341234$106.001. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????6. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????7. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????8. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????9. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????10. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????11. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????12. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????13. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????14. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????15. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????16. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????17. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????18. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????19. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????20. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????21. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????22. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????23. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????24. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????25. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????26. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????27. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????28. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????29. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????30. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????31. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????32. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????33. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????34. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????35. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????36. FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? TOTAL (this page) FORMTEXT ?????(Enter Grand Total amount as the Request Amount on Page 1, Section 2.)GRAND TOTAL (all pages) FORMTEXT ????? ................
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