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STATE OF FLORIDA <br />INDIAN RIVER COUNTY <br />THIS IS TO CERTIFY THAT THIS ISATRUE AND CORRECT <br />COPY OF THE ORIGINAL ON FILE IN THIS OFFICE. <br />�„ RYAN L. BUTLER, CLERK <br />Attachment I (Continued) <br />Request for Payment to Rural Community or Rural Area of <br />Opportunity <br />ITEMIZED LIST FOR PAYMENT REQUESTS <br />RECIPIENT: INDIAN RIVER COUNTY AGREEMENT #: DMS -P1-25-07-17 <br />Recipient's <br />Reference No. <br />(Warrant, Voucher, <br />Claim check, or <br />Schedule No.) <br />Date of delivery of <br />articles, completion <br />of work, or <br />performance <br />services. <br />DOCUMENTATION <br />List documentation (Recipient's purchase order, signed inventory <br />receipt, and name of the vendor or contractor/subcontractor) by <br />category and line item in the approved project application and <br />give a brief description of the articles or services. <br />Total Eligible <br />Costs <br />TOTAL <br />DMS -P1-25-07-17 Page 2 of 2 <br />