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TEXAS DEPARTMENT OF TRANSPORTATION - DIVISION OF AVIATION <br />RAMP GRANT -Request for Reimbursement Form <br />SECTION A [TxDOT COMPLETES 1-51 <br />Estimated Due Date: <br />Airport: San Marcos Municipal <br />Name of Payee: City of San Marcos <br />Texas Payee Identification Number: 17460022381000 <br />Address: 1807 AirportRoad San Marcos, TX 78666 <br />Date Received: <br />1. Grant Amount <br />2. Less Previous Approved Payments <br />3. AMOUNT APPROVED THIS PAYMENT <br />APPROVAL: <br />4. Project Manager <br />DATE OF REQUEST: <br />Request No.: <br />Total amount for invoices attached $ <br />Less 50% Sponsor Share $ <br />AMOUNT OF THIS PAYMENT REQUEST $ <br />5. Grant Manager Date <br />SECTION B: [SPONSOR COMPLETES 1-71 <br />1. Final Reimbursement Request [ ] Yes [ ] No <br />2. <br />3. <br />4. <br />5. <br />6. <br />7 <br />I, <br />do hereby certify that I am <br /> <br />50.000.00 <br /> <br />(Title of person certifying) <br />and that I am duly authorized to make this certification for and on behalf of the City of San Marcos. I <br />further certify that the attached invoice is correct and that it corresponds in every particular with the <br />supplies and/or services contracted for. I further certify that the account is true, correct, and unpaid. <br />Date <br />ATTACH COPY OF INVOICES TO THIS REQUEST <br />CERTIFICATION OF SPONSOR <br />TxDOT CSJ: M014SMRCO <br />PAY AS A KIND 31 VOUCHER <br />Fiscal Year: 2010 <br />Segment 76 <br />Dist/Div 42 <br />Function Code 870S <br />Object Code 384 <br />SIGNATURE