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Okaloosa County BOCC — December 18, 2012 — Payment Approval Form — reading text
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EXHIBIT I
CONTRACT/LEASE
PAYMENT APPROVAL FORM
COMPLETE AND FORWARD TO THE NEXT APPROVING DEPARTMENT
COMPLETED BY DEPARTMENT
DATE: 1/2/2013
VENDOR NAME: Moulton Construction, Inc. VENDOR #:
COUNTY AGREEMENT # (Contact Contract/Lease Coordinator, if unknown) C11-1914-CE
TASK COUNTY/FEMA
VENDOR ORDER # PROJECT # BUDGET
INVOICE # (if applicable) (if applicable) DEPARTMENT # ACCOUNT # AMOUNT
4 73831 562390 $78,240.00
TOTAL $78,240.00
APPROVED FOR PAYMENT (please initial, as applicable and date) :
ENGINEER/ARCHITECT/PROJECT MANAGER DATE:
COUNTY PROJECT MANAGER: AL DATE: 1/2/2013
DEPARTMENT HEAD:
DATE: UL. ‘yg L13
FINAL PAYMENT: YES On
CONTRACTS & GRANTS
DATE: CONTRACTS & GRANTS MANAGER:
DATE: COUNTY ADMINISTRATOR APPROVAL : (Only Payments $25,001 - $50,000)
FINAL PAYMENT APPROVAL (if needed):
PURCHASING DIRECTOR: (Only Contracts < = $25,000)
COUNTY ADMINISTRATOR : (Only Contracts between $25,001 to $50,000)
Contracts Over $50,000 — BCC Approved
COMPLETED BY FINANCE - ACCOUNTS PAYABLE ONLY
FISCAL YR:
DATE RECEIVED:
Form revised 1-20-2011