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�X111bit E3 <br /> tllinois Department <br /> of Transpori:ation Engineering Payment Report <br /> (Subtnit with Final Invoice } <br /> Prime Consultan# <br /> Name AEGOM Technical Services !nc <br /> Address 345 E Ash Decatur, lL 62526 <br /> Tefephone 217-875-4800 <br /> TiN Number <br /> Praject tnformation <br /> Local Agency Ci#y of Decatur <br /> Section Number 09-00933-01-BR <br /> Project Number 6WGY(165) <br /> Job Number D97-p09-19 <br /> This#orm is to verify the amount paid to the Sub-consultant on the above captioned contract. Under penalty of law for <br /> perjury or falsificatian,the undersigned certifies that work was executed by the Sub-consultant for the amount listed be(ow. <br /> Sub-Consultant Name TiN Number Actuaf Payment <br /> from Prime <br /> Qui En ineerin , (nc 20-4818431 <br /> Kaskaskia En ineerin Grau , LLC 20-5080586 <br /> WNKS 42-0943938 <br /> �ub-Consultant Total: <br /> Prime Consultant Total: <br /> To#al for aii Work <br /> Cam leted: <br /> Signature and title of Prime Consultant Dats <br /> Nate; The Department af Transportatian is requesting disclosure of information that is necessary to accamplish the sta#utory <br /> purpase as ou#lined under state and federal law. Discic�sure of this infarmatian is REQUIRED and shall be deemed as <br /> concurring with the payment amount specified above. <br /> Far informatian abou#IDOTs collection and use of canfidential informatian review the departmenYs Identitv Protection Policy. <br /> Page 7 of 8 BLR 0561 Q(Rev.11/08/17) <br /> Printed on 91241241810:24:12 AM <br />