HomeMy WebLinkAbout20240605075312331Quarterly Invoice Form
Request for Payment Cover Sheet
This request for payment cover sheet should be filled out and submitted with the invoices for
which you are requesting reimbursement. Request for reimbursement will not be processed
without the; request for payment cover sheet.
To be completed by the Awardee:
Name of Awardee: Town of Mansfield Date: 6/01/17
Project Title FY17 State Budget Earmark #7008-0900 "for the establishment of a nark at the
beginning of the Norton Rail -Trail in the Town of Mansfield"
Contract#: (MMARS Doc ID Found in ton right section of Standard Contract Form) 1 FY17
Legislative Exemption
Person preparing request: John F. Stanbrook
Total amount of invoices: $50,000.00 Number of invoices attached: 0 (estimates are attached)
The chart below should include overall project spending information (insert lines as needed
Line Item (use
budget lines in
Tree Cutt
Grubbing
Site Shaping,
Grading, Install
Underground
Conduit, Water
Service, and
Riverstone
White Vinyl
Fence (approx.
70 ft)
Riverstone (est.
48 tons @$75
Filter Fabric
24 (3-4ft)
Arborvitae
(purchase and
Total
50% Initial
Previous
Amount of
Balance
Allocation
amount
this invoice
invoiced
$6,000.00
$3,000.00
$0.00
$3,000.00
$3,000.00
$3,000.00
$1,500.00
$0.00
$1,500.00
$1,500.00
$15,000.00
$7,500.00
$0.00
$7,500.00
$7,500.00
$3,800.00
$1,900.00
$0.00
$1,900.00
$1,900.00
$3,600.00
$1,800.00
$0.00
$1,800.00
$1,800.00
$400.00
$200.00
$0.00
$200.00
$200.00
$2,000.00
$1,000.00
$0.00
$1,000.00
$1,000.00
Li=Item
bu
Total
50% Initial
Allocation
Previous
amount
invoiced
Amount of
this invoice
Balance
12(6ft)trees
$3,600.00
$1,800.00
$0.00
$1,800.00
$1,800.00
and shrubs<
(purchase and
install)
Sidewalk. _ :
$4,700.00
$2,350.00
$0.00
$2,350.00
$2,350.00
(concrete and
install)
3 Lights
$7,900.00
$3,950.00
$0.00
$3,950.00
$3,950.00
(Materials only
Total
1 $50,000.00
$25,000.00
$0.00
$25,000.00
$25,000,00
Below, please provide a brief summary of the work completed since the commencement of the
project or since the last request for reimbursement. All invoices submitted should accurately
reflect the work completed and not deviate from the scope of services provided in the contract.
'. Stanbrook, certify that the expenditures enumerated by this
the Contract, and the funds disbursed by the Executive Office of
>pment shall only be used to pay for the invoices and contractors
Mass Office of
ourism
10 Park Plaza
#4510
BOSTON, W
02116
US
617-973-8509'
Ship,
Shipment Receipt
Ship from:
y, CMD John F Stai
,ravel & TOWN Of
6 PARK R
MANSFIE
02048
Total weight: 0.25 LBS
Declared Value: 100.00 USD
Special Services: Direct signatu
Pickup/Drop-off: Drop off pack2
Billing Information:
Bill transportation to: MyAccom
Your reference:
P.O. no.:
Invoice no.:
Department no.:
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