CP-POP (4/1/27)
NEW YORK STATE DEPARTMENT OF TRANSPORTATION
REQUEST FOR PAYMENT FROM PAVE OUR POTHOLES (POP)
*
Required Entries for Each Submitted Project
MUNICIPAL DESCRIPTION
Name of Municipality:
*
Municipal Code:
*
PROJECT LISTING
CAPITAL PROJECTS FOR WHICH PAYMENT IS REQUESTED
TOTAL PROJECT COST
(Please enter this amount first)
REIMBURSEMENT REQUESTED
(Don''t exceed project cost)
1.
Route/Name/Other:
*
Location:
From
*
To
Project Type:
Hwy. Resurfacing
Hwy. Reconstruction
*
Mileage Treated:
Sub Project Type:
Please select one of the options above first
*
$
*
$
*
First Payment?
*
Yes
No
Final Payment?
*
Yes
No
2.
Route/Name/Other:
*
Location:
From
*
To
Project Type:
Hwy. Resurfacing
Hwy. Reconstruction
*
Mileage Treated
Sub Project Type:
Please select one of the options above first
*
$
*
$
*
First Payment?
*
Yes
No
Final Payment?
*
Yes
No
3.
Route/Name/Other:
*
Location:
From
*
To
Project Type:
Hwy. Resurfacing
Hwy. Reconstruction
*
Mileage Treated:
Sub Project Type:
Please select one of the options above first
*
$
*
$
*
First Payment?
*
Yes
No
Final Payment?
*
Yes
No
TOTAL AMOUNT CLAIMED:
$
CERTIFICATION
I hereby certify that the total amount claimed for this payment is for unreimbursed expenditures between the dates of
*
and
*
and all project costs submitted for reimbursement are in accordance with the “Program Guidelines” published at https://www.dot.ny.gov/programs/chips.
Street/Highway Superintendent Name:
*
_______________________________________________
Signature
Phone Number:
*
Date signed:
*
E-mail address:
*
IN ORDER FOR THE TOTAL AMOUNT CLAIMED TO BE PROPERLY CALCULATED & ALL REQUIRED ENTRIES TO APPEAR ON THE FORM, YOU MUST USE THE “PRINT,SIGN, & MAIL TO REGIONAL CHIPS REP” BUTTON
* NOTE:
Clicking on
Enter More Projects
Button will CLEAR your Project 1-3 Entries and allow you to enter more
