WPC  77WPC >?dA?.@4?N4?7O?O!?NO#?[OUr?=,<$^oZG7>   (  Standard'3,, , ,   UB ) 3    *    d +    d ,    d /0ghjklmnopqrstuvwxyz{|}~P2 * c:\inf42\forms\ad672.wpf c:\product\forms\informs\ad\ad672.wpfUS&& &&   >Y?df eh Terminal 1 ! d !  d      Terminal eb Arial " ! 2     d    Arial ev Times New Roman  ! 2 F  d    Times New Roman ? Ad A{?.z jV c:\inf41\database\ AD672.DBFhistory   i(AgreeNo     h AGREENO i%Year     h YEAR i'Amount     h AMOUNT i(AgyBill     h AGYBILL i(TransCd     h TRANSCD i&ActCd     h ACTCD i(ReqName     h REQNAME i'ReqAd1     h REQAD1 i'ReqAd2     h REQAD2 i(ReqCity     h REQCITY i&State     h STATE i$Zip     h ZIP i'ServNm     h SERVNM i(ServAd1     h SERVAD1 i(ServAd2     h SERVAD2 i)ServCity     h SERVCITY i'ServSt     h SERVST i(ServZip     h SERVZIP i)ServPerm      h SERVPERM  i(ListRef      h LISTREF  i(DateFrm     h DATEFRM i)ContThru     h CONTTHRU i)ApSymbol  @   h APSYMBOL@ i'WorkNo  @   h WORKNO@ i(T_1[A1]     h T_1_A1_ i(T_1[B1]     h T_1_B1_ i(T_1[C1]     h T_1_C1_ i(T_1[D1]     h T_1_D1_ i(T_1[E1]     h T_1_E1_ i(T_1[F1]     h T_1_F1_ i(T_1[G1]     h T_1_G1_ i(T_1[H1]     h T_1_H1_ i(T_1[I1] !    h T_1_I1_ i(T_1[J1] "    h T_1_J1_  i(T_1[K1] #    h T_1_K1_  i(T_1[L1] $    h T_1_L1_  i(T_1[M1] %    h T_1_M1_  i(T_1[N1] &    h T_1_N1_  i(T_1[A2] '    h T_1_A2_ i(T_1[B2] (    h T_1_B2_ i(T_1[C2] )    h T_1_C2_ i(T_1[D2] *    h T_1_D2_ i(T_1[E2] +    h T_1_E2_ i(T_1[F2] ,    h T_1_F2_ i(T_1[G2] -    h T_1_G2_ i(T_1[H2] .    h T_1_H2_ i(T_1[I2] /    h T_1_I2_ i(T_1[J2] 0    h T_1_J2_ i(T_1[K2] 1    h T_1_K2_ i(T_1[L2] 2    h T_1_L2_ i(T_1[M2] 3    h T_1_M2_ i(T_1[N2] 4    h T_1_N2_ i(T_1[A3] 5    h T_1_A3_ i(T_1[B3] 6    h T_1_B3_ i(T_1[C3] 7    h T_1_C3_ i(T_1[D3] 8    h T_1_D3_ i(T_1[E3] 9    h T_1_E3_  i(T_1[F3]! :    h T_1_F3_! i(T_1[G3]" ;    h T_1_G3_" i(T_1[H3]# <    h T_1_H3_# i(T_1[I3]$ =    h T_1_I3_$ i(T_1[J3]% >    h T_1_J3_% i(T_1[K3]& ?    h T_1_K3_& i(T_1[L3]' @    h T_1_L3_' i(T_1[M3]( A    h T_1_M3_( i(T_1[N3]) B    h T_1_N3_) i(T_1[A4]* C    h T_1_A4_* i(T_1[B4]+ D    h T_1_B4_+ i(T_1[C4], E    h T_1_C4_, i(T_1[D4]- F    h T_1_D4_- i(T_1[E4]. G    h T_1_E4_. i(T_1[F4]/ H    h T_1_F4_/ i(T_1[G4]0 I    h T_1_G4_0 i(T_1[H4]1 J    h T_1_H4_1 i(T_1[I4]2 K    h T_1_I4_2 i(T_1[J4]3 L    h T_1_J4_3 i(T_1[K4]4 M    h T_1_K4_4 i(T_1[L4]5 N    h T_1_L4_5 i(T_1[M4]6 O    h T_1_M4_6 i(T_1[N4]7 P    h T_1_N4_7 i(T_2[A1] Q    h T_2_A1_ i(T_2[B1] R    h T_2_B1_ i(T_2[C1] S    h T_2_C1_ i(T_2[D1] T    h T_2_D1_ i(T_2[E1] U    h T_2_E1_ i(T_2[F1] V    h T_2_F1_ i(T_2[G1] W    h T_2_G1_ i(T_2[H1] X    h T_2_H1_ i(T_2[I1] Y    h T_2_I1_ i(T_2[J1] Z    h T_2_J1_  i(T_2[K1] [    h T_2_K1_  i(T_2[L1] \    h T_2_L1_  i(T_2[M1] ]    h T_2_M1_  i(T_2[N1] ^    h T_2_N1_  i(T_2[A2] _    h T_2_A2_ i(T_2[B2] `    h T_2_B2_ i(T_2[C2] a    h T_2_C2_ i(T_2[D2] b    h T_2_D2_ i(T_2[E2] c    h T_2_E2_ i(T_2[F2] d    h T_2_F2_ i(T_2[G2] e    h T_2_G2_ i(T_2[H2] f    h T_2_H2_ i(T_2[I2] g    h T_2_I2_ i(T_2[J2] h    h T_2_J2_ i(T_2[K2] i    h T_2_K2_ i(T_2[L2] j    h T_2_L2_ i(T_2[M2] k    h T_2_M2_ i(T_2[N2] l    h T_2_N2_ i(T_2[A3] m    h T_2_A3_ i(T_2[B3] n    h T_2_B3_ i(T_2[C3] o    h T_2_C3_ i(T_2[D3] p    h T_2_D3_ i(T_2[E3] q    h T_2_E3_  i(T_2[F3]! r    h T_2_F3_! i(T_2[G3]" s    h T_2_G3_" i(T_2[H3]# t    h T_2_H3_# i(T_2[I3]$ u    h T_2_I3_$ i(T_2[J3]% v    h T_2_J3_% i(T_2[K3]& w    h T_2_K3_& i(T_2[L3]' x    h T_2_L3_' i(T_2[M3]( y    h T_2_M3_( i(T_2[N3]) z    h T_2_N3_) i(T_2[A4]* {    h T_2_A4_* i(T_2[B4]+ |    h T_2_B4_+ i(T_2[C4], }    h T_2_C4_, i(T_2[D4]- ~    h T_2_D4_- i(T_2[E4].     h T_2_E4_. i(T_2[F4]/     h T_2_F4_/ i(T_2[G4]0     h T_2_G4_0 i(T_2[H4]1     h T_2_H4_1 i(T_2[I4]2     h T_2_I4_2 i(T_2[J4]3     h T_2_J4_3 i(T_2[K4]4     h T_2_K4_4 i(T_2[L4]5     h T_2_L4_5 i(T_2[M4]6     h T_2_M4_6 i(T_2[N4]7     h T_2_N4_7 i)LvFactor     h LVFACTOR i%FICA     h FICA i'OvHead     h OVHEAD i'ReqSgn  @   h REQSGN@ i(ReqDate     h REQDATE i)ReqTitle      h REQTITLE  i'NmCont  @   h NMCONT@ i)ReqPhone     h REQPHONE i'ReqFTS     h REQFTS i(ReqComm     h REQCOMM i'ApSign  @   h APSIGN@ i'ApDate     h APDATE i(ApTitle      h APTITLE  i'ApName  @   h APNAME@ i(ApPhone     h APPHONE i&ApFTS     h APFTS i'ApComm     h APCOMM i%Bill     h BILL i)TypeAcct     h TYPEACCT ?J@d @}?Nh,%, 2) REIMBURSEMENT OR ADVANCE OF FUNDS AGREEMENT O !"#                             P  &&    ]hX d 1 AGREEMENT NUMBER (25) AgreeNo!"-./56789:;>?@ABCG                         P #      $      '   Y@$.,! *  < && = &&     Y,X d 2 FISCAL YEAR (4) Year!"-./5"67 89: ;>?@ABCG                         P #      $      ' 4  Y@$.,! *  < &&  = &&     cX d 3 ESTIMATED AMOUNT (11) Amount!"-./5,6789:;>?@ABCG                         P #      $      ' 4   $.,! *  < &&  = &      V0       P    XH d 4 AGY. BILL  d  IND. (1) = !"#      K                       P  &&     7 H AgyBill!"-./5=6789:;>?@ABCG                         P #      $      '   Y@$.,! *  < && = &&      X  d 5 TRANS.  d  CODE (1) D !"#      K                       P  &&     7   TransCd!"- ./5D6789:;>?@ABCG                         P #      $      '   Y@$.,! *  < && = &&     "X  d 6 ACTION  d  CODE (1) J !"#      K                       P  &&     5"  ActCd!"- ./5J6789:;>?@ABCG                         P #      $      '   Y@$.,! *  < && = &&     r  & AGENCY REQUESTING SERVICE  ' !"#                             P  &     &  AGENCY PERFORMING SERVICE  *' !"#                             P  &    Nr d NAME (32) ReqName!"-./567'89:';>?@ABCG                         P #      $      '    Y@$.,! *  < && = &&     Yr@ d 1ST LINE ADDRESS (32) ReqAd1!"-./567'89:';>?@ABCG                         P #      $      '    Y@$.,! *  < && = &&     Yr d 2ND LINE ADDRESS (32) ReqAd2! "-./56 7'89:';>?@ABCG                         P #      $      '    Y@$.,! *  < && = &&     Nr`   d CITY (21) ReqCity! "-./56 789:;>?@ABCG                         P #      $      '   Y@$.,! *  < && = &&     L `  d STATE (2) State! "-./56 789:;>?@ABCG                         P #      $      '   Y@$.,! *  < && = &&     N` ( d ZIP CODE (10)( Zip! "-./56 7 89: ;>?@ABCG                         P #      $      '    Y@$.,! *  < && = &&     M d NAME (32) ServNm! "-./5*67'89:';>?@ABCG                         P #      $      '    Y@$.,! *  < && = &&     Z@ d 1ST LINE ADDRESS (32) ServAd1!"-./5*67'89:';>?@ABCG                         P #      $      '    Y@$.,! *  < && = &&     Z d 2ND LINE ADDRESS (32) ServAd2!"-./5*6 7'89:';>?@ABCG                         P #      $      '    Y@$.,! *  < && = &&     O`   d CITY (21) ServCity!"-./5*6 789:;>?@ABCG                         P #      $      '   Y@$.,! *  < && = &&     M`  d STATE (2) ServSt!"-./5A6 789:;>?@ABCG                         P #      $      '   Y@$.,! *  < && = &&     RR!` ( d ZIP CODE (10)( ServZip!"-./5G6 7 89: ;>?@ABCG                         P #      $      '    Y@$.,! *  < && = &&      V        P    r %@ } 9 SERVICES TO BE PERFORMED (Give brief explanation and basis for determining cost of services. Attach additional sheet if needed.)% ServPerm!"-./567O89:O;>?@ABCG                         P #      $      '    Y@$.,! *  < && = &&     h0%  }& 10 LIST REFERENCES TO CORRESPONDENCE RELATIVE TO THIS WORK (Requesting agency only.) (50)% ListRef!"-./567O89:O;>?@ABCG                         P #      $      '    Y@$.,! *  < && = &&     rP  & DURATION OF AGREEMENT  ' !"#                             P  &    P! & METHOD OF PAYMENT  *' !"#                             P  &    {h$  } EFFECTIVE DATE (From)$ DateFrm!"-"./56789:;>?@ABCG                         P #      $      '    Y@$.,! *  < && = &&     5@HASVALUE (DateFrm) and #UPDATONLY    DateFrm  ~      :@datevalue (@datetext (DateFrm, "%2-%1-%5"))   DateFrm   %2-%1-%5  "  #  7@VALUE (@DATETEXT (DateFrm,"%5"))<=29   DateFrm   %5  "  x         x@SETVALUE (DateFrm,@DATEVALUE (@CONCAT (@DATETEXT (DateFrm,"%2-%1"),"-20",@DATETEXT (DateFrm,"%5"))),TRUE)    DateFrm   DateFrm   %2-%1  "   -20   DateFrm   %5  "      #       Z `  d CONTINUING THROUGH` ContThru!"-#./56789:;>?@ABCG                         P #      $      '    Y@$.,! *  < && = &&     6@HASVALUE (ContThru) and #UPDATONLY    ContThru  ~      ;@datevalue (@datetext (ContThru, "%2-%1-%5"))   ContThru   %2-%1-%5  "  #  8@VALUE (@DATETEXT (ContThru,"%5"))<=29   ContThru   %5  "  x         {@SETVALUE (ContThru,@DATEVALUE (@CONCAT (@DATETEXT (ContThru,"%2-%1"),"-20",@DATETEXT (ContThru,"%5"))),TRUE) !  ContThru   ContThru   %2-%1  "   -20   ContThru   %5  "      #       yr$ & FINANCING   !"#                             P  &     VPX %      P    ?'?7Oy` ' d REIMBURSEMENT * !"#                             P  &&    wD) }& BILLING FREQUENCY , !"#                             P  x&     |L$ + d ADVANCE OF FUNDS > !"#                             P  &&    u<- }& TYPE OF ACCOUNT @ !"#                             P  x&     n !. & (REQUESTING AGENCY --- WHEN NOT SERVICED BY NFC)  F !"#                             P  &&    drpz d APPROPRIATION SYMBOL AND TITLEz ApSymbol!"-/./567'89:';>?@ABCG                         P #      $      ' @  Y@$.,! *  < && = &&     yr0 & FINANCING     !"#                             P  &     1 & (REQUESTING AGENCY --- WHEN SERVICED BY NFC)   E !"#                             P  &&    h2 dU AGENCY  d CODE ! !"#                             P  &&    3 d: FUND  d: CODE ! !"#                             P  &&    4 d ACCT.  dl STATION  ! !"#                             P  &&    5 q& ACCOUNTING CLASSIFICATION !, !"#                             P  &&    m6 d" A " !"#                             P  &&    m| (7 dN B "  !"#                             P  &&    m8 d  C #"  !"#                             P  &&    mTX9 d D -" !"#                             P  &&    m: d E 2"  !"#                             P  &&    LH; d OBJECT  d CLASS >! !"#                             P  &&    r < d AMOUNT E!  !"#                             P  &&    hX%@T 1 T_1#$(v),-#.O/012456789                                    P ! " $%&')*                       Y@$.,!  ( &&  3 &&    A     A     A     A     ?    ?    ?    ?    ?(     ?    ?    ?X    ?    ?X    ?    ?h    ?H    ?     *">$%&')*                      Y@$.,!  ( &&x    *"?$%&')*                      Y@$.,!  ( &&x    *"@$%&')*                      Y@$.,!  ( &&x    *"A$%&')*                      Y@$.,!  ( &&x    *("B$% &')*                       Y@$.,!  ( &&x    *"C$%&')*                      Y@$.,!  ( &&x    *"D$%&')*                      Y@$.,!  ( &&x    *X"E$%&')*                      Y@$.,!  ( &&x    *"F$%&')*                      Y@$.,!  ( &&x    *X "G$%&')*                      Y@$.,!  ( &&x    * "H$%&')*                      Y@$.,!  ( &&x    *h "I$%&')*                      Y@$.,!  ( &&x    *H "J$%&')*                      Y@$.,!  ( &&x    , "K$% &')*                        $.,!  ( &x    *"L$%&')*                      Y@$.,!  ( &&     *"M$%&')*                      Y@$.,!  ( &&     *"N$%&')*                      Y@$.,!  ( &&     *"O$%&')*                      Y@$.,!  ( &&     *("P$% &')*                       Y@$.,!  ( &&     *"Q$%&')*                      Y@$.,!  ( &&     *"R$%&')*                      Y@$.,!  ( &&     *X"S$%&')*                      Y@$.,!  ( &&     *"T$%&')*                      Y@$.,!  ( &&     *X"U$%&')*                      Y@$.,!  ( &&     *"V$%&')*                      Y@$.,!  ( &&     *h"W$%&')*                      Y@$.,!  ( &&     *H"X$%&')*                      Y@$.,!  ( &&     ,"Y$% &')*                        $.,!  ( &&    *"Z$%&')*                      Y@$.,!  ( &&     *"[$%&')*                      Y@$.,!  ( &&     *"\$%&')*                      Y@$.,!  ( &&     ??O*"]$%&')*                      Y@$.,!  ( &&     *( "^$% &')*                       Y@$.,!  ( &&     *!"_$%&')*                      Y@$.,!  ( &&     *""`$%&')*                      Y@$.,!  ( &&     *X#"a$%&')*                      Y@$.,!  ( &&     *$"b$%&')*                      Y@$.,!  ( &&     *X%"c$%&')*                      Y@$.,!  ( &&     *&"d$%&')*                      Y@$.,!  ( &&     *h'"e$%&')*                      Y@$.,!  ( &&     *H("f$%&')*                      Y@$.,!  ( &&     ,)"g$% &')*                        $.,!  ( &&    **"h$%&')*                      Y@$.,!  ( &&     *+"i$%&')*                      Y@$.,!  ( &&     *,"j$%&')*                      Y@$.,!  ( &&     *-"k$%&')*                      Y@$.,!  ( &&     *(."l$% &')*                       Y@$.,!  ( &&     */"m$%&')*                      Y@$.,!  ( &&     *0"n$%&')*                      Y@$.,!  ( &&     *X1"o$%&')*                      Y@$.,!  ( &&     *2"p$%&')*                      Y@$.,!  ( &&     *X3"q$%&')*                      Y@$.,!  ( &&     *4"r$%&')*                      Y@$.,!  ( &&     *h5"s$%&')*                      Y@$.,!  ( &&     *H6"t$%&')*                      Y@$.,!  ( &&     ,7"u$% &')*                        $.,!  ( &&    ghXw d  2 # !"#                             P  &&    gXx d 2 # !"#                             P  &&    gXy d) 4  # !"#                             P  &&    gXz d) 5 # !"#                             P  &&    h| X({ d< 10 #  !"#                             P  &&    gX| d) 5 ## !"#                             P  &&    gtX} d 3 )# !"#                             P  &&    gTXX~ d 4 -# !"#                             P  &&    gX d9 1 2# !"#                             P  &&    gXX d 4 4# !"#                             P  &&    gX d9 1 9# !"#                             P  &&    gXh du 2 ;# !"#                             P  &&    gLXH de 4 ># !"#                             P  &&    g Xt d 9 E#  !"#                             P  &&    g%Xh du 2 O# !"#                             P  &&     V%X@       P    T!  & (PERFORMING AGENCY)  +D !"#                             P  &&    yh! & FINANCING  +  !"#                             P  &    h`" dU AGENCY  d CODE , !"#                             P  &&    `" d: FUND  d: CODE , !"#                             P  &&    `" d ACCT.  dl STATION  , !"#                             P  &&    `" q& ACCOUNTING CLASSIFICATION ,, !"#                             P  &&    m(# d" A - !"#                             P  &&    m| (#( dN B -  !"#                             P  &&    m(# d  C #-  !"#                             P  &&    mT(#X d D -- !"#                             P  &&    m(# d E 2-  !"#                             P  &&    L`"H d OBJECT  d CLASS >, !"#                             P  &&    r `" d AMOUNT E,  !"#                             P  &&    h#%@T 1 T_2#$(),-..O/012456789                                    P ! "$%&')*                       Y@$.,!  ( &&  3 &&    A     A     ?7?NOA     A     ?    ?    ?    ?    ?(     ?    ?    ?X    ?    ?X    ?    ?h    ?H    ?     *"$%&')*                      Y@$.,!  ( &&    *"$%&')*                      Y@$.,!  ( &&    *"$%&')*                      Y@$.,!  ( &&    *"$%&')*                      Y@$.,!  ( &&    *("$% &')*                       Y@$.,!  ( &&    *"$%&')*                      Y@$.,!  ( &&    *"$%&')*                      Y@$.,!  ( &&    *X"$%&')*                      Y@$.,!  ( &&    *"$%&')*                      Y@$.,!  ( &&    *X "$%&')*                      Y@$.,!  ( &&    * "$%&')*                      Y@$.,!  ( &&    *h "$%&')*                      Y@$.,!  ( &&    *H "$%&')*                      Y@$.,!  ( &&    , "$% &')*                        $.,!  ( &    *"$%&')*                      Y@$.,!  ( &&     *"$%&')*                      Y@$.,!  ( &&     *"$%&')*                      Y@$.,!  ( &&     *"$%&')*                      Y@$.,!  ( &&     *("$% &')*                       Y@$.,!  ( &&     *"$%&')*                      Y@$.,!  ( &&     *"$%&')*                      Y@$.,!  ( &&     *X"$%&')*                      Y@$.,!  ( &&     *"$%&')*                      Y@$.,!  ( &&     *X"$%&')*                      Y@$.,!  ( &&     *"$%&')*                      Y@$.,!  ( &&     *h"$%&')*                      Y@$.,!  ( &&     *H"$%&')*                      Y@$.,!  ( &&     ,"$% &')*                        $.,!  ( &&    *"$%&')*                      Y@$.,!  ( &&     *"$%&')*                      Y@$.,!  ( &&     *"$%&')*                      Y@$.,!  ( &&     *"$%&')*                      Y@$.,!  ( &&     *( "$% &')*                       Y@$.,!  ( &&     *!"$%&')*                      Y@$.,!  ( &&     *""$%&')*                      Y@$.,!  ( &&     *X#"$%&')*                      Y@$.,!  ( &&     *$"$%&')*                      Y@$.,!  ( &&     *X%"$%&')*                      Y@$.,!  ( &&     *&"$%&')*                      Y@$.,!  ( &&     *h'"$%&')*                      Y@$.,!  ( &&     *H("$%&')*                      Y@$.,!  ( &&     ,)"$% &')*                        $.,!  ( &&    **"$%&')*                      Y@$.,!  ( &&     *+"$%&')*                      Y@$.,!  ( &&     *,"$%&')*                      Y@$.,!  ( &&     *-"$%&')*                      Y@$.,!  ( &&     *(."$% &')*                       Y@$.,!  ( &&     */"$%&')*                      Y@$.,!  ( &&     *0"$%&')*                      Y@$.,!  ( &&     *X1"$%&')*                      Y@$.,!  ( &&     *2"$%&')*                      Y@$.,!  ( &&     *X3"$%&')*                      Y@$.,!  ( &&     *4"$%&')*                      Y@$.,!  ( &&     *h5"$%&')*                      Y@$.,!  ( &&     *H6"$%&')*                      Y@$.,!  ( &&     ,7"$% &')*                        $.,!  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(As applicable) WorkNo!"-./5*67'89:';>?@ABCG                         P #      $      ' @  Y@$.,! *  < && = &&     Xh0*t d 16 LEAVE FACTORt LvFactor!"-./5667 89: ;>?@ABCG                         P #      $      '   !<6 !<6G$.,! *  < &&  = &       V*       P    ih* d (3) 6 !"#                             P  &&     i* d (2) 6 !"#                             P  &&     S0* d 17 FICA FACTOR FICA!"-./5 667 89: ;>?@ABCG                         P #      $      '   !<6 !<6G$.,! *  < &&  = &      V*       P    i* d (3)  6 !"#                             P  &&     i* d (2) 6 !"#                             P  &&     Y| 0*p d 18 OVERHEAD FACTORp OvHead!"-./566789:;>?@ABCG                         P #      $      '   !<6 !<6G$.,! *  < &&  = &&     Vx*       P    i| * d (3) 6 !"#                             P  &&     ix*t d (2) !6  !"#                             P  &&      X 0*       P    h+ & REQUESTING AGENCY APPROVAL  8' !"#                             P  &    + & PERFORMING AGENCY APPROVAL  *8' !"#                             P  &    Mh, d SIGNATURE ReqSgn! 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