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Okaloosa County BOCC — September 3, 2013 — payment approval form — reading text
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CONTRACT/LEASE
PAYMENT APPROVAL FORM
COMPLETE AND FORWARD TO THE NEXT DEPARTMENT
c= =)
COMPLETED BY DEPARTMENT
DATE: 10/9/2013
VENDOR C.W. Roberts Contracting Inc. VENDOR #: 20101504
CONTRACT/LEASE#: C07-1453-PW [
VENDOR TASK COUNTY/FEMA BUDGET
INVOICE # ORDER # PROJECT # DEPARTMENT | ACCOUNT # AMOUNT $
Cf Applicatle) (If Applicable) lA #
48305 3202 ¥ 563167 4,459.13
3202 563490) 9,969.09
302 ZOSINCO
Total 14,428.22
APPROVED FOR PROGRESS PAYMENT (please sign, as applicable and date)
CONTRACTOR'S ENGINEER/ARCHITECT/PROJECT MANAGER: DATE:
COUNTY SUPERVISOR/PROJECT MANAGER C2 fay Sittuensys DATE: /04
DEPARTMENT DIRECTOR: John Hofstad
CONTRACTS & GRANT MANAGER: Va
DATE:
oes
DATE:
COUNTY ADMINISTRATOR: DATE:
(Payments> $25,000.)
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FINAL PAYMENT
FINAL PAYMENT = YES {£ NO__ (if "Yes", forward to Purchasing Services Coordinator for Close-Out)
DATE: PURCHASING DIRECTOR:
(Per Initial Agreement)
AE DATE: joO~ 24-13
{All Contracts)
DATE: /@ VEIL
+ . - &
CONTRACTS & GRANTS MANAGER: Keon Oe fo Qu
COUNTY ADMINISTRATOR APPROV. AD
(Per Initial Agreement) 7
DATE: BOARD APPROVAL: =
(Per Initial Agreement) for
: SS
COMPLETED BY FINANCE - ACCOUNTS PAYABLE ONLY
FISCAL YEAR:
DATE RECEIVED:
REVIEWD BY:
Z186