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i <br /> Exhibit B <br /> Illinois Department <br /> f of Transportation Engineering Payment Report <br /> Prime Consultant <br /> Name <br /> Address <br /> I Telephone <br /> TIN Number <br /> Project Information <br /> I <br /> i <br /> Local Agency <br /> i Section Number <br /> Project Number <br /> 1 Job Number <br /> This form is to verify the amount paid to the Sub-consultant on the above captioned contract. Under penalty of law for <br /> perjury or falsification,the undersigned certifies that work was executed by the Sub-consultant for the amount listed below. <br /> Sub-Consultant Name TIN Number Actual Payment <br /> from Prime <br /> Sub-Consultant Total: <br /> Prime Consultant Total: <br /> F_ <br /> Total for all Work <br /> Completed: <br /> Signature and title of Prime Consultant Date <br /> Note: The Department of Transportation is requesting disclosure of information that is necessary to accomplish the statutory <br /> purpose as outlined under state and federal law. Disclosure of this information is REQUIRED and shall be deemed as <br /> concurring with the payment amount specified above. <br /> ag o BCR-056f0JRevv.9/06) <br /> Printed on 10/30/201412:05:02 PM <br /> I <br />