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Jobs Created and/or Retained for ARRA Funded Drinking Water Projects Project Owner: Project Number: DEH

Project Owner DUNS Number: Contractor / Consultant:

Contractor / Consultant DUNS Number:

Circle the applicable Quarter: (JulSept) (OctDec) (JanMar) (AprJun) FTE's: Signature:

Year: 20

Date:

Name: Title: Phone Number: ( ) Please Fax completed form to:

Tony Patnode, PE at Fax # 9197154374,

or Please email a scanned copy of the completed form to: [email protected] Please send signed original forms to: Tony Patnode, PE Public Water Supply Section 1634 Mail Service Center Raleigh, NC 276991634 This form is due no later than the 5th of the month following each applicable quarter. Completed forms showing FTEs for Subcontractors and Project Consultants should be included along with completed Prime Contractor forms. This Form and EPA guidance are located on the main American Recovery and Reinvestment Act of 2009 Web Site for Public Water Supply Systems: http://www.deh.enr.state.nc.us/pws/recovery.htm under the Jobs Reporting bullet.

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