HOST Expense Certification

Please fill out this expense certification form and attach all back-up documentation as attachments, using the buttons below. Please note that there is an approximate 20MB total limit on attachments (i.e. all attachments together should not be more than 20MB in total.) If you have attachments that exceed this size limit, please use the “Attach Additional Documents to Your Invoice” button on the HOST webpage, below the button that you used for this form.

Invoice #

Supplier Contract (SC) Number

Purchase Order #

Assigned Project Specialist

City Contract Number

Is this for a grant reimbursement?

YesNo

Company Name

Contractor's First Name

Contractor's Last Name

Email Address

Project Address

Total Contract Amount

Amount Expended to Date

Total Requested Amount

We certify that the current expenses in the amount of $

were incurred for services provided as per the above contract, and/or that all labor and material were contributed to the construction or improvements at the above address. Also, we have not been reimbursed for these expenses prior to this time or by any other source, and that we will save the City of Denver harmless from any lien filed on the subject property as a result of its disbursement

Is this the FINAL HUD Draw Request?

Yes
No

Attachments

Please attach the following back up documentation using the “Choose File” buttons below. Please keep in mind the TOTAL 20MB file size limit for all documents you attach.

Expense Certification Cover Sheet

Summary Sheet of all costs requested

Other Attachment #1

Other Attachment #2

Other Attachment #3

Other Attachment #4

Other Attachment #5

Other Attachment #6

Other Attachment #7

Other Attachment #8

Other Attachment #9

Other Attachment #10

Other Attachment #11

Name and Title of Authorized Person

Certified by:

Certified Date:

If the HOST team has questions regarding this invoice, please indicate a contact, email and a phone number: *

If the HOST team has questions regarding this invoice, please indicate a contact and a phone number

Contact Information