Claim for Reimbursement

Aviation

Airport Name

Contract Number

Project Number

Request Number

Claim Status

Iowa DOT Grant Amount ($) (No comma)

DOT Percent Participation of Eligible Costs

Prior Amount Reimbursed ($) (No comma)

Payments with this request ($) (No comma)

Current Reimbursement Request ($) (No comma)

Email (for verification of claim submittal)

Expense Summary

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Invoices/Proof of Payment

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Additional supporting documents (1)

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Additional supporting documents (2)

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Additional supporting documents (3)

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For additional information on aviation programs, contact Shane Wright at 515-239-1048 or shane.wright@iowadot.us.

First Name

Last Name

Choose how to sign

Draw Type

I hereby certify that all eligible project activities for which reimbursement is requested have been completed in substantial compliance with the project agreement and the laws of the State of Iowa and the ordinances of the CITY/COUNTY. I certify that the items claimed for payment are proper and true and that no part of this claim has been paid by DOT.