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Get KY TC 69-008 2017-2024

Agreement Start Date INVOICING INFORMATION PARTIAL FINAL BILL NO. AMOUNT OF THIS BILL Purchase Order Number ex P02 xxx xxxxxxxxxx Statute/Agreement Type KRS 177. MAIL TO Highway Chief District Engineer ATTN District Utility Agent find at http //transportation.ky. 035 Keep Cost Agreement/PRDO Amount Change Orders TOTAL AMOUNT OF PREVIOUS BILLS TOTAL BILLS TO DATE COMPANY CERTIFICATION I certify to the extent applicable the attached invoice is a true statement of costs incurred by our Company in constructing the most economical type of facilities in the new location as will satisfactorily meet the same service requirements as the old facilities in the old location on subject project all materials for which we seek reimbursement adhere to federal Buy America provisions as required and all costs listed are eligible for payment by KYTC. Records of invoiced work are to be retained as defined in the referenced agreement and may be subject to audit. Gov/district. htm GENERAL ROAD PROJECT INFORMATION This section is as defined in the Agreement as executed. Location / Description Fiscal Federal Number if applicable County if more than one use page 2 State Number Route/Road Name Item or AAR-DOT Number Project Description COMPANY INFORMATION Company Name Company Contact Name Company Address as identified in the Agreement street address address 2 city state zip DATE INVOICED WORK BEGAN not to precede State Letter date Company Invoice Number if applicable Remit to check if same as Agreement Enter all dates using m/d/yyyy format. TC 69-008 Page 1 of 2 Rev. 1/2017 Kentucky Transportation Cabinet Division of Right of Way Utilities UTILITY/RAIL AGREEMENT STATEMENT OF CHARGES INSTRUCTIONS Company shall fully complete this form. Submit this fully completed form Company invoice and documentation of charges in triplicate. For additional orders use page 2. 3 TOTAL FROM PG 2 TOTAL FOR CABINET USE ONLY Checked District Utility Agent Date Recommended/Approved Chief District Engineer Approved Director Division of Right of Way Utilities Signature Title Rev. 4/2013 ADDT L CHANGE ORDERS TOTAL PAGE 2 ACTUAL PERCENTAGE AMOUNT if applicable This section is only needed if any information is entered on page 2 COMPANY VALIDATION I accept the certification terms on page 1 in reference to the work performed as defined on page 1. Final invoicing is to be submitted within 1 year of completion of work per agreement and statute to be considered for payment. COUNTY automatically transfers to page 1 Initial NOTE If the amount of this bill applies to more than one county the correct distribution MUST be shown on the following lines. .

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