03/15/12 FAA/Application for Payment #5FRE:p - e ` r
Federal !
Administration
Memorandum
Date: March 15, 2012
From: Gary Gates, HLN-610
2725 Skyway Dr; Ste 2, Helena, MT 59602
(406) 449-5230
To: Accounts Payable Branch, AMZ-110
Subject: ACTION: Application for Payment Number: 5 Partial
Kalispell City Airport
Kalispell, MT
AIP Project No. 3-30-0043-003-2010
Grant Contract Number: DOT-FAIONM-2032
A scanned copy of FAA Form 5100-60 is submitted for payment. Based on the
representation and certification contained in the payment request, I find the amount of
$20,045 (shown on line V) to be an allowable project cost, not previously paid, and
approved for payment.
a. Accumulated previous payments......... $64,908.00
b. Amount approved this payment........... $20,045.00
c. Total accumulative payments .............. $84,953.00
d. Maximum grant amount. ....... ............ $92,910.00
e. Remaining balance ........................... $7,957.00
Gary tes, HLN-610
CITY Or- KALISPELL
1 Attachment 03/'23/12 3�@3 PN ras`'
cc: ANM-613
City of Kalispell
Stelling Engineers, Jeff Walla
�ceaun f 4s)_2 -- 000 - 33i1a8-L�bl�
Glacier Bank 2929-7082-5: Account Transactions
FAA PLANNING GRT
RECEIPT N0;P2190?4 AMOUNT
FMN FA'A PLANNING Gr:T 20;045.00
PROJ33000430032010/CONTDOT-Ff IRM-2032
PAYMENT RECEIVED AMOUNT
AE TOTAL 20,045000
03/23/2012
Chea # 1(.9oPiI
FAA TREAS 310 EDI MISC ACH Ent ry Memo Posted Today
0o, I 0 q 9.7 to iin a ;) ej -IV 5l'w,f I i h7
20,045.00
3-0?9 -12, C;�
JTL.-iY REPORT AND REQUEST FOR REIMBURSEMENT
OMB APPROVAL NO. 0348.0002
PAGE OF
FOR CONSTRUCTION PROGRAMS
1 PAGES
1, TYPE OF REQUEST
2. BASIS OF REQUEST
(SeeinGluclionaonbacy
j 7 FINAL jXI PARTIAL
X
C ] CASH C ] ACCRUAL
`iDERAL SPONSORING AGENCYAND ORGANIZATIONAL ELEMENT TO
4. FEDERAL GRANT OR OTHER
5. PARTIAL PAYMENT REQUEST NO.
41GH THIS REPOR71$ SUBMITTED
IDENTIFYING NUMBER
OOT-FAA
ASSIGNED BY FEDERAL AGENCY
Five (5)
DOT•FAI C NM-2032
S. EMPLOYER IDENTIFICATION
7. RECIPIENT'S ACCOUNT NUMBEF
PERIOD COVERED BY THIS REQUEST
FROM tMonth, day, year)
TO {Month, day, year) _ -
NUMBER
OR IDENTIFYING NUMBER
81-60D1281
3-30.0043.003-2010
1211712CII
WJ2012
9. RECIPIENT ORGANIZATION
10. PAYEE (Where Check is lobe 4ent if different than ffem 9)
Nemec City of Kalispell
Name:
No, and srmal: 201 1st Avenue East
No. and Sin3eC
City, State and Kalispell, MT 59901
City, state and
ZIP Coda:
Z;P Code:
11. STATUS OF FUNDS
CLASSIFICATION
TOTAL
No. 1-3
No. 4
No, 5
a. Administrative expense
$0_00
b. P 1[rninaryexpense
$0.00
c- Land, structures, right-of-way
$0.00
d, Architectural engineering basic fees
$47,525.00
$20,500.00
$21,099.76
$89,424,76
e. Other architectural engineering fee
$0,00
f. Project inspection fees
$0.00
g. Land development
$0,00
h, Relocation expense
$0.00
L Relocation payments to individuals and businesses
$0,00
')emDlition and removal
$0.00
.;. Construction and project improvement cost
%00
1. Equipment
30,00
m. Miscellaneous cost
$0,00
n. Total cumulative to data {sum oftines a fhru m)
$47,825.00
$20,500.00
$21,099,76
$89,424.76
o. Deductions for program income
p. Net cumulative to date (line n minus line o)
$47,826.00
$20,500.00
$21,099.76
$89,424.76
q. Federal share to date
$84,953.00
r. Rehabilitation grants (100% reimbursement)
$0.00
s. Total Federal share (sum oftines q and r)
$84,953.00
I. Federal payments previously requested
$64,908.00
u. Amount requested for reimbursement
$20,045.00
v. Percentage of physical completion of project (Grant Amount $92,910,00)
91.4%
12.CERTIFICATION
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL
DATE REPORTSUBMITED
a.
RECIPIENT
�/l L i I
1 certify that to the best of my knowledge and
-
TYPEDO Eb44<MMDTITLE
TELEPHONE rang roae,n�xc
belief the billed costs or disbursements are in
accordance with the terms of the project and that
the reimbursement represents the Federal share
Charles Harball
(406) 753-7703
due which has not been previously requested and
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL
DATE SIGNED
that an inspection has been performed and all
work is in accordance with the terms of the award.
318f2012
b.
REPRESENTATIVE
CERTIFYING
TO LINE I
TYPED OR PRINTED NAME AND TITLE
TELEPHONE (A- a,—w.
'
GIIQ EAM90.'e
Jeff Walla, PE
406-765.8602
AU I nU KiZ-tu r V N LV t AL KtrKUUUD I IUN STANDARD FORrd 271 (Rev, 7,97)
PREVIOUS EDITION USABLE Pro$400e0 by OMB CimularA-102 and A-110
271-103
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