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05t28;'~99~ 1~:~5 5~~-29~-2835 H~NN~ h~ICELD04~iNE'v P~GE 04 <br />1. t.NAGES FOR HIREO MOC7ERS: <br />Attach proof of worker's wage rate, <br />Fiil in dates, workers names; ~hours workEd, and rate requ <br />a,~. Wo~fcer's Name Hvurs <br />1Nork~d Hourly <br />Rate Total <br />15 9~ Ca itol Cit Traf (Bekins} $1,141.08 <br />3/15/9~ Arden's Cabinet Shop 6,720.00 <br /> <br /> <br />2. EQUIPM ENT RENTAL: Flll in dete used_ t voe nf pn~iinmpnt hn~~ra ~~ao~ 9~ <br />or other documentat~on ~f expense. <br />Z~'~ <br />r„ `' ~'~ <br />o.Y <br />~j <br />d rate. Attach receipts <br />Oete Equ(pment Used ~ Hours <br />Used Hourly <br />Rate Total <br /> <br /> <br /> <br /> <br /> <br />3. OTHER EXPENSES' Dafe_ d~scrioti~n ~nr~ ~n~t ~~ i~ t F~ <br />documentation oF expense. <br />9 filled in. Attach invoice ar othe~ <br />~at~ Description Cost rQtal <br />3~~ 9~ ~L1,.~ ' f t.,..o t.~rkll.~I~-r 3, j s. o v <br />, <br />3 :f ~ ~., ~~s. o ~ <br />~ c ~ - o. eo <br /> <br /> <br />'-~p -r l~ c,. : <br />~~f~ q3~ ~ o~ <br />~orrn 223 {~~ss) RELOCATION <br />ACTUAL COST NON-RESiDENTIAL MOVE CLAIM <br />