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Division of Environmental Health <br />Section of Drinking Water Protection <br />P.O. Box 64975 <br />St. Paul, Minnesota 55164-0975 <br />651/201-4700 <br />Source Water Protection Com etitive Grants Inv <br />Exhibit B <br />p <br />GRANTEE INFORMATION <br />PWSID: <br />System: <br />$ <br />Address: <br />$ <br />Program Contact Person: <br />Phone: <br />Fax: <br />E-mail: <br />$ <br />$ <br />1 INVOICE INFORMATION <br />Is this the final invoice? <br />❑ Yes <br />lii <br />No <br />WORK ITEMS AND EXPENDITURE DESCRIPTION Expenditure Cost Share <br />use an additional page if necessary <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br />Total <br />Deduct amount of cost share <br />Net Invoice Amount to be Paid <br />$ <br />$ <br />DISCLAIMER AND SIGNATURE 1 declare that no part of this claim has been previously billed to MDH, and that the Total Expenditures reflect only <br />charges related to the source water protection project. I also declare that the data on this document Is correct and all transactions that support this claim were <br />made In accordance with all applicable Federal and State statutes and regulations, <br />Authorized Grantee Signature <br />Date <br />FOR MINNESOTA DEPARTMENT OF HEALTH USE ONLY <br />Grant Manager Signature Date <br />PO: <br />Approved by: <br />Period of Service: Date sent to F.S: <br />