Get Form Pr 20 Voucher

117. TOTAL ACTUAL COST TOTAL PARTICIPATING COST PRO-RATA OF CLAIMED FROM U.S. TOTAL AMOUNT CLAIMED FROM U.S. LESS PREVIOUS PAYMENTS NET AMOUNT I certify that the cost shown in this voucher have been incurred in accordance with terms of project agreements applicable State and Federal laws or regulati ons and that no claim has previously been submitted for costs claimed. STATE HIGHWAY AGENCY DATE SIGNATURE OF AUTHORIZED OFFICIAL I certify that supporting records for costs claimed and the referenced project if applicable have been subjected to required reviews approvals and inspections by the Federal Highway AMOUNT SUBMITTED SIGNATURE OF FHWA REPRESENTATIVE ADJUSTMENTS AMOUNT APPROVED FORM PR-20 Rev. 8-07 DATE APPROVED PREVIOUS EDITIONS ARE OBSOLETE Save Data Only Clear Form Save Data Form STATEMENT OF COSTS INCURRED UNDER PROJECT AGREEMENT ITEM NO. This collection of information is Mandatory and will be used to reimburse State Departments of Transportation for costs incurred on Federal-aid projects. Public reporting burden is estimated to average 30 minutes per response including the time for reviewing instructions searching existing data sources gathering and maintaining the data needed and completing and reviewing the collection of information* Please note that an agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is 2125-0507. The expiration date for this OMB number is Nov* 30 2007. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to Information Collection Clearance Officer Federal Highway Administration 1200 New Jersey Avenue SE Washington DC 20590. Office of Management and Budget Paperwork Reduction Project 2135-0507 Washington D*C* 20503 Federal Highway Administration Finance Division HCFM-30 1200 New Jersey Avenue SE STATE VOUCHER NO. U* S* Department of Transportation Administration VOUCHER FOR WORK PERFORMED UNDER PROVISIONS OF THE FEDERAL AID AND FEDERAL HIGHWAY ACTS AS AMENDED FHWA VOUCHER NO. APPROPRIATION FHWA SCHEDULE NO. THE UNITED STATES DR* TO Insert official or depositary named in project agreement PAID BY ADDRESS For use of Paying Office STATE VOUCHER TYPE Check Appropriate Block CURRENT BILLING VOUCHER PERIOD FROM OTHER PROGRESS TO FEDERAL AID PROJECT NO. FINAL VOUCHER Use Form FHWA-1447 for Final Voucher for a project constructed under certi fication acceptance or secondary road procedures 23 U*S*C. This collection of information is Mandatory and will be used to reimburse State Departments of Transportation for costs incurred on Federal-aid projects. Public reporting burden is estimated to average 30 minutes per response including the time for reviewing instructions searching existing data sources gathering and maintaining the data needed and completing and reviewing the collection of information* Please note that an agency may not conduct or sponsor and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.