ARIZONA DEPARTMENT OF TRANSPORTATION
Multimodal Planning Division
Federal Fiscal Quarters

MOBILITY MANAGEMENT (§5310)-(§5316)-(§5317)
GRANTEE INVOICE TO ADOT
Agency

SITE LOCATION:
JPA#

COG/MPO:

QUARTER THIS INVOICE:

GRANT AWARD YEAR:

1st

2nd

3rd

4th

PROGRAM

5310

5316
5317

PROGRESS REPORT IS REQUIRED TO PAY INVOICE
REQUEST FOR PAYMENT
Total Contract
Amount

ACTUAL EXPENSES
5310 MM Capital Expenses (not vehicles)

Total Invoiced
to Date

$0.00

$0.00

Total Requested
this Invoice

$0.00

Remainder on
Contract

$0.00

*Less In-Kind or Cash Match ( 90/10 Capital)

$0.00

$0.00

$0.00

$0.00

SUB-TOTAL PAYABLE

$0.00

$0.00

$0.00

$0.00

5316 MM Capital Expenses (not vehicles)

$0.00

$0.00

$0.00

$0.00

*Less In-Kind or Cash Match ( 90/10 Capital)

$0.00

$0.00

$0.00

$0.00

SUB-TOTAL PAYABLE

$0.00

$0.00

$0.00

$0.00

5317 MM Capital Expenses (not vehicles)

$0.00

$0.00

$0.00

$0.00

*Less In-Kind or Cash Match ( 90/10 Capital)

$0.00

$0.00

$0.00

$0.00

SUB-TOTAL PAYABLE

$0.00

$0.00

$0.00

$0.00

TOTAL PAYABLE

$0.00

$0.00

$0.00

$0.00

PAYMENT SHOULD BE MAILED TO:
Agency Name:

Attention:

Address:

City/State/Zip

Phone:

Email:

SIGNATURES
By my signature below, the grantee certifies that appropriate local match funds have been expended towards this project and assures that the grantee has engages in
local and regional coordination activities, including its Regional Coordination Plan, to the best of its ability.

Signed:

Date:

Print Name:

Title:

OK to Pay
Charge to Project Number:
Signature:
Date:
Comments:

ADOT MM Invoice 2012

0

Reviewed and Approved by ADOT: