TOTAL Subsidy Due This Claim (Excluding GST)

Subsidy claim form

Council name: / ABN:
Project name (As per final approval letter):
Funding program name: DSLGUWSASEnvironmental Infrastructure ProgramEnvironmental Infrastructure Research ProgramLandfill Remediation Assesment ProgramLGBCWSSQ150 Legacy Infrastructure ProgramQueensland Fluoridation Assistance ProgramRegional Centres ProgramRural Living Infrastructure ProgramSecurity Improvement ProgramShoreline Erosion Management ProgramSmaller Communities Assistance ProgramUrban Drought Water ProgramWater and Sewerage Program
Project number (As per final approval letter): / Contact person:
Is the organisation registered for GST?
YES NO / GST registration date:
Funding: / Total cost
(Excluding GST) $ / Subsidy
$ / Council funding
$ / Other state contributions
$ / Commonwealth contributions
$ / Other contributions
$
Estimated / Approved
Actual (spent to date)
Work description / Non-subsidisable cost
(excluding GST) / Subsidisable cost
(Excluding GST)

Project status

/ % Complete Final claim
Subsidy due (Excluding GST)
Less previous subsidy claims paid (Excluding GST)

TOTAL subsidy due this claim (Excluding GST)

CERTIFICATION: (TO BE SIGNED BY CHIEF EXECUTIVE OFFICER OR APPROPRIATELY DELEGATED OFFICER)
I certify that all reports and/or attachments required for this claim are attached, the above amounts are true and accurate, and (where necessary) the stated portion of work on the project has been completed in accordance with Local Government Building Approvals and that these expenditures are for works approved under the program listed above

Revised forecasts

If this claim is for a project 25% or more complete, please
provide the following information:
Future claim date / Claim amount
Name and Position
Signature Chief Executive Officer / Accountable Officer / Date
OFFICE USE ONLY / Date Received from Council:
/ / / Actual Payment Date:
/ /
Claim is valid, amount correct & within approved project funds:
Signature: ______
Position: ______/ Claim details recorded in CLASS by:
Signature: ______
Position: ______
CLASS Transaction No.: / CLASS details checked by:
Signature: ______
Position: ______/ Payment dated and voucher no. entered into CLASS by:
Signature: ______
Position: ______
CLASS Vhr No:
Date: / / / Date: / / / Date: / / / Date: / /