771 Summary of Work orders (Inspection by Agency Field Engin

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is 0572-0059. The time required to complete this information is estimated to average 30 minutes per
response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information.
U.S. DEPARTMENT OF AGRICULTURE
RURAL UTILITIES SERVICE

SUMMARY OF WORK ORDERS

SYSTEM DESIGNATION

(Inspection By RUS Field Engineer)
INSTRUCTIONS - Prepare 3 copies. Original to be forwarded to Area Office of RUS after RUS Field
Engineer has approved construction. For detailed instructions see RUS Bulletin 382-2,
Appendix B.

SUMMARY NUMBER

APPROVAL IS REQUESTED FOR THE ENCUMBRANCE OF LOAN FUNDS AS SHOWN IN COLUMN "h" FOR COMPLETED CONSTRUCTION OF SYSTEM
IMPROVEMENTS AND EXTENSIONS OR FOR PURCHASES OF STATION APPARATUS AND EXEMPT MATERIALS:
COST OF CONSTRUCTION

LESS ADVANCES NOT REQUIRED

WORK
ORDER
NO.

a

LABOR AND
OTHER

MATERIAL

b

TOTAL

c

d

$0.00

$0.00

TOTAL COST

REUSABLE
MATERIALS
SALVAGED

e

$0.00

$0.00

STATION
APPARATUS &
EXEMPT MAT'L.

OTHER

NET
ADVANCES

(Explain)

REQUIRED

f

g

h

$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 that 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

NAME OF BORROWER

DATE

APPROVAL OF CONSTRUCTION
The above construction or purchase has been reviewed and is approved from an engineering standpoint.

DATE

RUS FIELD ENGINEER

ACCOUNTING VERIFICATION (RUS USE ONLY)

RUS Form 771 (Rev.10-75)

Expires: XX/XX/20XX