Exhibit 5-D - Sample Right Of Way Invoice Form Page 2

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Local Assistance Procedures Manual
EXHIBIT 5-D
Sample Right of Way Invoice
1. I certify that to the best of my knowledge and belief the above data is correct; that adequate title to the necessary right of
way has been acquired for the herein above described federal-aid project in the name of the ______________________
Local Agency Name
for the amount of just compensation based on bona fide appraisals duly qualified as required by the right of way
procedures of the Federal Highway Administration and other written justification now contained in the _______________
Local Agency Name
files, in accordance with procedures as submitted and accepted by the Director.
2. I further state that this certification is made in my official capacity as ____________ pursuant to Section 1.31 of Title 23
Title
of the Code of Federal Regulations and Section 121 of Title 23, United States Code, for the purpose of securing, pursuant
thereto, by the _____________________, federal-aid funds in connection with the above designated federal-aid highway
Local Agency Name
project, and that neither I nor to the best of my knowledge, any officer, agent, or employee of the ___________________
City
_________________________ authorized in any official capacity to perform services in connection with the appraisal or
County
acquisition of any such right of way has any interest, or contemplates any benefit from any transaction which involves
acquisition of property for right of way for such project, other than as herein disclosed.
Signature, Title and Unit of Local Agency Representative
Phone No.
For questions regarding this invoice, please contact:
Name
Phone No.
*
Please round down the figures to the lowest cent. Federal rules do not allow rounding up.
**
• Indirect cost for this project equals the direct cost base expense (i.e., direct salaries & wages plus fringe benefits)
for this project multiplied by the approved indirect cost rate.
• Indirect cost reimbursement will not apply to direct costs, i.e., payment of construction contracts and right of
way purchases, not included in the direct cost base.
• An indirect rate must be approved by Caltrans every fiscal year to be used for only those costs incurred for
that year.
NOTE:
Rental income may be retained by local agencies, but must be used for Title 23 purposes.
Original & 2 copies to DLAE
Distribution:
 
Page 2 of 2
March 2, 2015

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