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Okaloosa County BOCC — 2013 meeting #1182 (date undetermined) — Contract Payment Approval Form — reading text
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CONTRACT/LEASE
PAYMENT APPROVAL FORM
COMPLETE AND FORWARD TO THE NEXT DEPARTMENT
= —]}
COMPLETED BY DEPARTMENT
DATE: 10/14/2013
VENDOR NAME: ELECTRIC MOTOR REPAIR SERVICE VENDOR #: 002445
CONTRACTILEASEY: 614203-ws COQ~1U9S-LUS
TASK COUNTY/FEMA
VENDOR BUDGET
ORDER # PROJECT # ACCOUNT # AMOUNT $
INVOICE # Of Applicable) Of Applicable) DEPARTMENT #
12438 4101 546022 2,610.00
12414 ALOt [C04] — 546022- =f 2405" 810.00 |-
12455 4401 (4 546022 GIZ¢45 810.00
TOTAL | $ 4,230.00 (bY
APPROVED FOR P ROGRESS PAYMENT wiease sign, as applicable and date)
COUNTY SUPERVISOR/PROJECT MANAGER.
CONTRACTOR'S ENGINEER/ARCHITECT/PROJECT E
. AYO WM Gpichn
DEPARTMENT DIRECTOR:
CONTRACTS & GRANT MANAGER: (Sent AOA ‘4 Oo Ko Vun
COUNTY ADMINISTRATOR:
(Payments> $25,000.)
apt (.
DATE:
DATE: of 1S /Z01z
pate: _19/15/20v%
DATE:
ied LS
DATE:
WA FINAL PAYMENT
FINAL PAYMENT YES V.,NO__ (if"¥Yes", forward to Purchasing Services Coordinator for Close-Out)
DATE: . PURCHASING DIRECTOR:
(Per Initial Agreement)
DATE: \\ral-ts CONTRACTS & GRANTS MANAGER: (S cdlo pps
(All Contracts)
DATE: L/ /22 VE COUNTY ADMINISTRATOR APPROVAL FE
i (Per Initial Agreement)
DATE: BOARD APPROVAL:
(Per Initial Agreement)
COMPLETED BY FINANCE - ACCOUNTS PAYABLE ONLY
FISCAL YEAR:
DATE RECEIVED:
REVIEWED BY:
Saya