This Will Trigger the Final 10 Per Cent Final Payment

2016–17 Works for Queensland [W4Q]

Final Certificate Form

This will trigger the final 10 per cent final payment.

As per the Funding Deed of Agreement, this Certificate of Expenditure form needs to be completed to certify: 1. All expenditure has occurred. 2. The number of jobs supported, sustained or created.

Council details

Council

Contact officer Phone number

Position Email

2016-17 W4Q Council $ Final actual expenditure $ allocation Total jobs supported, Actual number of jobs sustained or supported, sustained or created as per created. List of Project submission. If the total jobs supported, sustained or created as per List of Projects submitted does not equal the final numbers of actual jobs supported, sustained or created (i.e. more/less), please provide an explanation.

I certify that: 1. The actual expenditure to date has occurred and equates to 100 percent of the approved 2016–17 W4Q allocation. 2. The projects are consistent with the 2016–17 W4Q Funding Program guidelines, as submitted on the List of Projects form and any other subsequent correspondence as endorsed by the Minister or Department. 3. As per the 2016–17 W4Q Funding Program guidelines and clause 6.1 of the Funding Deed of Agreement, Council has recognised the Queensland Government funding in all media and other communications. 4. The projects were completed by 30 November 2017. 5. Appropriate signage is in place in accordance with the department’s Funding Acknowledgement Guidelines – attach a photograph of the plaque or sign acknowledging the contribution of the department (where relevant).

Signed by Date

Chief Executive Officer or formal delegate

Name: Position:

Please email the final project report to the relevant DILGP representative for your council or email to the address below:

2016-17 W4Q Final Certificate Form Page 2 of 3 [email protected]

[email protected]

2016-17 W4Q Final Certificate Form Page 3 of 3