Orange County NC Website
Browse       Search
DocuSign Envelope ID:C80FF651-3BCF-4358-88DA-30DA3334E081 <br /> ATTACHMENT C-2:NCPRO Coronavirus grant <br /> Monthly Reimbursement Request <br /> Attachment C-1 must accompany this form to receive reimbursement from NCPRO. <br /> RECIPIENT COMPLETION INFORMATION:Email completed form to: ttUpIoadLmk. <br /> PART A:Summary of Funding Received and Spent <br /> January <br /> Reimbursement <br /> August September October November December Requestfor <br /> Contract Total Funding July Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement Reimbursement December <br /> NAME OF RECIPIENT Agreement Authorized by HB Request Request Request Request Request Request Expenses Total Received to Point of Contact Point of Point of Contact <br /> gORGANIZATION: Number 1043: Advance (Details in Part B) (Details in Part B) (Details in Part B) (Details in Part B) (Details in Part B) (Details in Part B) (Details in Part B) Date Name Point of Contact Title: Contact Email Phone Number <br /> Or ChcpC'my/by and for p60-00-12-02 $10,750 Laurie Paolicelli Director,Chapel Hill/Orange LPaolicelli@Visit(919)259-1658 <br /> theCoun apil12sitors Burege County Visitors Bureau Chapel Hill.org <br /> au <br /> PLEASE REMEMBER INDIRECT COST ALLOCATION AND PERCENTAGE OF ADMINISTRATION COST ARE UNALLOWABLE <br /> PART B:Detailed Expense(In lieu of completing Part B manually,detailed information can be exported from your systems in Excel or.CSV format,however,at minimum,the requested fields must be provided) <br /> Actual Employee <br /> Recipient Name <br /> Required Monthly Hours Dedicated to Employee Expenses Other Service Other Expenses(e.g.related Is the Vendor a <br /> Date of Invoice, Employee Name Employee ID Employee Title Subcontract Hours Worked COVID (Payroll and benefits Expenses(e.g. Goods Expenses charges not assigned in Historically <br /> r or a Number or Contracted Labor Expenses(e.g. Equipment TOTAL <br /> Subrecipient Name payroll,or or or cost for employee Expenses utilities,telephone, construction, (e.g.supplies, Expenses to <br /> H-M and described Expenditures Underutilized <br /> Contractor Invoice Number Purchased <br /> servi Vendor Name or or Description of Item ce, Total Invoice Invoice quantity that are dedicated to data,lease related PPE) by recipient,such as, Business(HUB)7 <br /> maintenance) <br /> Amount or COVID-19) expenses) patient services) (YES or No) <br /> If of Patients Served <br /> Ex.xRecipientNamev vendor 4/1/2020 joe vendor INV 123 reagents $ 8,975.00 30 $ 8,975.00 $8,975.00 NO <br /> Ex.«RecipientName, 4/5/2020 jane doe EMP ID a345 researcher 160.00 120 $ 6,000.00 $6,000.00 NA <br /> em to ee <br /> Ex.vRecipientName» 4/28/2020 pet store INV 75892 cages $ 3,216.00 5 $ 3,216.00 $3,216.00 yes <br /> contractor <br /> Ex.«ReclplentNamea $ - <br /> Subrecipient <br /> $ <br />