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75 <br />Division of Environmental Health Exhibit A <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 Plan Implementation Grants <br />Invoice <br />141 <br />Wnl rk Ttema�sand T+',xnendifaee'neverinhnn —use aia'aAdit.icmal nage Ifneclessarv� <br />$ <br />$ <br />"Total Expenditures ':'i $ <br />Deduct amount of advance received i $ <br />—T <br />t, <br />Net Invoice Amount to be Paid _ �3 a�.� , NI; <br />I declare that no part of this claim has been previously billed to MDH, and that the'rotal Expenditures rellect only charges related to the source <br />water protection project. I also declare that the data on this document is correct and all transactions that support this claim were made in <br />accordance with all applicable Federal and State statutes and regulations. <br />Authorized Grantee Signature Date <br />For Minnesota Department of health Use Only: <br />Grant Manager's Signature <br />Date <br />1"nvo9eb information <br />itu` <br />Is this the final invoice? <br />❑ <br />Yes <br />❑ <br />No <br />141 <br />Wnl rk Ttema�sand T+',xnendifaee'neverinhnn —use aia'aAdit.icmal nage Ifneclessarv� <br />$ <br />$ <br />"Total Expenditures ':'i $ <br />Deduct amount of advance received i $ <br />—T <br />t, <br />Net Invoice Amount to be Paid _ �3 a�.� , NI; <br />I declare that no part of this claim has been previously billed to MDH, and that the'rotal Expenditures rellect only charges related to the source <br />water protection project. I also declare that the data on this document is correct and all transactions that support this claim were made in <br />accordance with all applicable Federal and State statutes and regulations. <br />Authorized Grantee Signature Date <br />For Minnesota Department of health Use Only: <br />Grant Manager's Signature <br />Date <br />