SFN 13842 Request for Reimbursement Non-Federal Project

REQUEST FOR REIMBURSEMENT NON-FEDERAL PROJECT

NORTH DAKOTA AERONAUTICS COMMISSION | SFN 13842 (01-2025)
About You

Who is completing this form?
First name
Last Name
Your email
example@example.com
What is your role?

I am the engineering firm/otherI am the manager/airport authority member
Whose signature is required on this form? Enter their email here:
example@example.com
DATE

MonthDayYear
Date
AIRPORT
REQUEST NUMBER
PROJECT DESCRIPTION
DATE AWARD GRANTED

MonthDayYear
Date
AMOUNT AWARDED
AWARDED AMOUNT FOR FORM
DATE SUPPLEMENTAL GRANT AWARDED (IF APPLICABLE)

MonthDayYear
Date
SUPPLEMENTAL AMOUNT AWARDED (IF APPLICABLE)
SUPPLEMENTAL AWARDED AMOUNT FOR FORM

The invoices listed below were issued for this project. Please list invoices from oldest to newest date and attach the invoices.
Invoice #1
Invoice Date

MonthDayYear
Date
Invoice Number
Invoice From/For
Amount
Amount for form 1
Do you have another invoice?

YESNO

Invoice #2
Invoice Date

MonthDayYear
Date
Invoice Number
Invoice From/For
Amount
Amount for form 2
Do you have another invoice?

YESNO

Invoice #3
Invoice Date

MonthDayYear
Date
Invoice Number
Invoice From/For
Amount
Amount for form 3
Do you have another invoice?

YESNO

Invoice #4
Invoice Date

MonthDayYear
Date
Invoice Number
Invoice From/For
Amount
Amount for form 4
Do you have another invoice?

YESNO

Invoice #5
Invoice Date

MonthDayYear
Date
Invoice Number
Invoice From/For
Amount
Amount for form 5
Do you have another invoice?

YESNO

Invoice #6
Invoice Date

MonthDayYear
Date
Invoice Number
Invoice From/For
Amount
Amount for form 6
Do you have another invoice?

YESNO

Invoice #7
Invoice Date

MonthDayYear
Date
Invoice Number
Invoice From/For
Amount
Amount for form 7
Do you have another invoice?

YESNO

Invoice #8
Invoice Date

MonthDayYear
Date
Invoice Number
Invoice From/For
Amount
Amount for form 8
Do you have another invoice?

YESNO

Invoice #9
Invoice Date

MonthDayYear
Date
Invoice Number
Invoice From/For
Amount
Amount for form 9
Do you have another invoice?

YESNO

Invoice #10
Invoice Date

MonthDayYear
Date
Invoice Number
Invoice From/For
Amount
Amount for form 10
Do you have another invoice?

YESNO

Invoice #11
Invoice Date

MonthDayYear
Date
Invoice Number
Invoice From/For
Amount
Amount for form 11
Do you have another invoice?

YESNO

Invoice #12
Invoice Date

MonthDayYear
Date
Invoice Number
Invoice From/For
Amount
Amount for form 12

ATTACHMENTS

Cancelof
Total of all Invoices
Total of all Invoices
GRANT PAYMENT DUE
Percent State Match
Calculation for hidden percentage
GRANT PAYMENT DUE
Who is your airport planner?

Adam (East)Grant (West)
Do you have any comments?
Signature

Clear
TITLE
Date

MonthDayYear
Date
Should be Empty: