Form 771a-Summary of Work Order

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U.S. DEPARTMENT OF AGRICULTURE
RURAL UTILITIES SERVICE
SUMMARY OF WORK ORDERS
(Inspection By Licensed Engineer Or Borrower's Staff Engineer)

SYSTEM DESIGNATION

INSTRUCTIONS-Prepare 4 copies. Original & 1 copy to be forwarded to the SUMMARY NUMBER
RUS Field Engineer after the construction has been inspected and
certified. For detailed instructions, see RUS Bulletin 382-2,
Appendix B.

APPROVAL IS REQUESTED FOR THE ENCUMBRANCE OF LOAN FUNDS AS SHOWN IN COLUMN ''h'' FOR COMPLETE CONSTRUCTION
OF SYSTEM IMPROVEMENTS AND EXTENSIONS FOR PURCHASES OF STATION APPARATUS AND EXEMPT MATERIALS.
LESS ADVANCES NOT REQUIRED
COST OF CONSTRUCTION
NET
WORK
REUSABLE
STATION
OTHER
ADVANCES
LABOR
AND
ORDER
MATERIALS
APPARATUS &
(Explain)
MATERIAL
TOTAL COST
REQUIRED
OTHER
NO.
SALVAGED
EXEMPT MAT'L
g
d
c
a
e
b
h
f

TOTAL

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

CERTIFICATION
I certify that, (1) the total costs and net requirements for the construction included above are the actual costs and net
requirements for loan funds reflected in the permanent records of this organization, (2) construction, if any, which did
not conform to the ACD or SLP approved by RUS has received RUS approval, (3) construction of extensions, if any, to serve
subscribers in areas not included in existing loans, has been approved by RUS, (4) all the required acceptance tests have
been made on the construction and the results were satisfactory (5) any corrections required on the portions of
construction that were field-inspected have been made on all the construction included in the summary, and (6) the
requirements of the "Buy American" provision have been complied with where any foreign made materials or equipment were
used in the construction. I further certify regulatory body and other approvals required for this construction have been
obtained and that there have been no previous requests for approval of the net advance required for the construction
covered hereby.

AUTHORIZED SIGNATURE AND TITLE
DATE

NAME OF BORROWER
INSPECTION - CERTIFICATION

I hereby certify that sufficient inspection has been made of the construction reported by this summary to give me
reasonable assurance that the construction complies with applicable specifications and standards and meets appropriate
code requirements as to strength and safety. This certification is in accordance with acceptable engineering practice.

NAME OF INSPECTION FIRM

INSPECTION PERFORMED BY

SIGNATURE OF LICENSED ENGINEER

DATE

LICENSE NUMBER

SIGNATURE OF BORROWER'S STAFF ENGINEER
ACCOUNTING VERIFICATION (RUS USE ONLY)

RUS FORM 771a

10-75