Exhibit 5-D - Sample Right Of Way Invoice Form

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Local Assistance Procedures Manual
EXHIBIT 5-D
Sample Right of Way Invoice
E
5-D
S
R
W
I
XHIBIT
AMPLE
IGHT OF
AY
NVOICE
(Prepare on Letterhead of Local Agency)
 
Date of Invoice: ________________________
DLAE Name
_____________________________________
California Department of Transportation
District Local Assitance Address
_____________________________________
_____________________________________
_____________________________________
Billing Number:________________________
1, 2…, or Final
Invoice Number:_______________________
Local Agency’s Invoice Number
Federal-aid Project Number:____________________
Prefix Project Number (Fed. Agreement #)
Tax Identification Number:_____________________
Agency IRS ID Number
Date Project Accepted by City/County:____________
Accepted Date or “Ongoing” if not Final
Project Location:______________________________
____________________________________________________________
____________________________________________________________________________________
Expenditure Authorization or Advantage Project Number:________________
Reimbursement for Federal funds is claimed pursuant to Local Agency-State Agreement No. ________________,
Program Supplement No. ________________, executed on ______________.
Capital
Support
Total
Federal Appropriations Code
Federal Authorization Date
Federal/State Participating costs From
To
Total Indirect Costs to Date
$ 4,147.00
$ 4,147.00
Total Direct Costs to Date
$ 1,133,907.00
$ 243,642.00
$ 1,377,549.00
Less: Nonparticipating Costs
($ 20,750.00)
($ 64,356.00)
($ 85,106.00)
Federal Participating Costs to Date
$ 183,433.00
$ 1,296,590.00
$ 1,113,157.00
Less Participating Costs on Previous
($ 980,165.00)
($ 150,794.00)
($ 1,130,959.00)
Invoice
Change in Participating Costs
$ 132,992.00
$ 32,639.00
$ 165,631.00
Federal Reimbursement Ratio State
88.53%
88.53%
Reimbursement Ratio (if applicable)
Amount of this Claim
$ 117,737.82
$ 146,633.13
$ 28,895.31
$ 146,633.13
TOTAL INVOICE AMOUNT
INDIRECT COST CALCULATION
Right of Way Indirect Costs:
Fiscal Year 2012-2013
Fiscal Year 2013-2014
Direct Cost Base Expense
$ 10,740.49
$ 1,944.00
Approved Indirect Cost Rate
33.00%
31.00%
Subtotal**
$ 602.64
$ 3,544.36
Total Indirect Costs to Date for Right of Way ______________ (this Amount is carried to the front of the invoice under the
$ 4,147.00
Right of Way column)
 
Page 1 of 2
March 2, 2015

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