2-COMPLETE STREETS REIMBURSEMENT FY2017 closeout
MASSDOT PROCESS FOR COMPLETE STREETS FUNDING PROGRAM REIMBURSEMENT
To receive reimbursement for approved items and work tasks associated with the Ch 90I Complete Streets Funding Program, the City/Town submits the following forms to document expenditures
for reimbursement. These forms apply to both Tier 2 Technical Assistance and Tier 3 Construction Project reimbursements. The following form is submitted with the Chapter 90 List of Materials
HED-454 Form, and copies of invoices to your District State Aid Engineer.
The form Reimbursement Request [562KB])andList of Materials (454 Form) [121KB]can be found at https://www.massdot.state.ma.us/highway/DoingBusinessWithUs/LocalAidPrograms/Chapter90Program/Chapter90Forms.aspx.
COMPLETE STREETS-TIER 3 – REIMBURSEMENT REQUEST
City/Town:
Northampton
Project:
#98848---Pleasant Street Complete Streets
Project request was approved on
January 13, 2017
for
$
400,000
at 100% Reimbursement Rate =
$
400,000
.
1)
Attached are forms which document payment of approved expenditures totaling
$
for which we are requesting
$
340,952.39
at the approved reimbursement rate of 100%.
2)
The amount expended to date on this project is
$
340,952.39
.
3)
Is this request for a FINAL payment on this project?
Yes XX No
4)
Remarks:
This will close out state Fiscal Year 2017. Final Fiscal Year 2018 invoice expected in August, 2017.
CERTIFICATION
I hereby certify under penalties of perjury that the charges for labor, materials, equipment, and services itemized and summarized on the attached forms are true and correct, and were
incurred on this project in conformance with the MassDOT Highway Division Policies and established Municipal Standards that were approved for this project.
Wayne Feiden
Director Planning Sustainability
July 11, 2017
(Signed)
(Municipal Highway Official Title)
(Date)
I/we certify under penalties of perjury that the items as listed or summarized on the attached forms were examined; that they are in conformity with our existing wage schedule, equipment
rates, and all applicable statutes and regulations; that they are properly chargeable to the appropriation(s) designated for this work; and that Executive Order No. 195, dated April
27, 1981 and Chapter 11, Section 12 is acknowledged as applicable.
REVIEWED AND APPROVED FOR TRANSMITTAL
by
Signed:
Joyce Karpinski
(Accounting Officer’s Title)
Mayor David Narkewicz
(Duly Authorized)
DATE
July 11, 2017