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<br />Docusign Envelope ID: 6DA6840A-CBC0-4053-80F1-F219D97CE273 <br />INVOICE REPORT - EXHIBIT C <br />Cost Reimbursement Summary <br />TO: Cindy Giraldo, Chief Financial Officer <br />900 Wilshire Blvd.Ste 1700 <br />Los Angeles CA 90027 <br />Southern California Association of Governments Date: <br />Invoice #:AccountsPayable@scag.ca.gov <br />Billing Period: <br />MOU #: <br />OWP #: <br />MOU Term Date: <br />Project Title: <br />Sub-recipient Name: <br />Agency Project Manager Name: <br />Project Manager Email Address: <br />SCAG Project Manager Name: <br />CBO Name: <br />Full Project Budget Amount <br />Remaining Budget <br />$ <br />$ <br />- <br />- <br />Percentage of Project Budget Spent <br />Overall Percentage of Work Completion <br />#DIV/0! <br />0.00% <br />Previously <br />Invoiced <br />YTD <br />ExpenditureCost Categories Budget Current Invoice Balance <br />Task #1 - Input Task Name $-$-$-$-$- <br />In ProcessTask #2 - Input Task Name <br />Task #3 - Input Task Name <br />Task #4 - Input Task Name <br />Task #5 - Input Task Name <br />$ <br />$ <br />$ <br />$ <br />- <br />- <br />- <br />- <br />$ <br />$ <br />$ <br />$ <br />- <br />- <br />- <br />- <br />$ <br />$ <br />$ <br />$ <br />- <br />- <br />- <br />- <br />$ <br />$ <br />$ <br />$ <br />- <br />- <br />- <br />- <br />$ <br />$ <br />$ <br />$ <br />- <br />- <br />- <br />- <br />Task #6 - Input Task Name $-$-$-$-$- <br />GRAND TOTAL $-$-$-$-$- <br />Please send check to: <br />Agency Name <br />Address <br />City/State/ZIP <br />By signing this report under penalty of perjury, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the expenditures, disbursements and <br />cash receipts are for the purposes and objectives set forth in the terms and conditions of the award. I am aware that any false, fictitious, or fraudulent information, or the omission of any <br />material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise. I will retain all supporting documentation as required and <br />make it available upon request. I will refund any audit disallowances to SCAG. <br />Signature of a CBO Authorized Official Title <br />Full Name of an Official who is Authorized to Legally Bind the <br />Organization (CBO)Date <br />Signature of Sub-recipient Authorized Official Title <br />Full Name of an Official who is Authorized to Legally Bind the <br />Organization (Sub-recipient)Date <br />Legend:Formulas <br />For Input