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Name of Agency /City: <br />Project Title: <br />Page 3 of 5 <br />SUMMARY STATEMENT OF QUARTERLY PROJECT COSTS <br />(Contractual Services) <br />Date: <br />Claim Number: <br />Item Date Check /ACH <br />Vendor Name Description Paid Number Amount <br />TOTAL CONTRACTUAL SERVICES AMOUNT: <br />.00 <br />NOTE: Copies of all invoices, cancelled checks, purchase orders for this request must be attached <br />to process this reimbursement. <br />