771a Summary of Work Orders

OMB No 0572-0059
Exp: xx/xx/20xx

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

SYSTEM DESIGNATION

SUMMARY
INSTRUCTIONS- Prepare 4 copies. Original & 1 copy to be forwarded to the RUS Field Engineer
after the construction has been inspected and certified. For detailed instructions, see RUS Bulletin 382-2, NUMBER
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.
WORK
ORDER
NO.
a

COST OF CONSTRUCTION
LABOR AND
OTHER

MATERIAL

TOTAL COST

b

c

d

LESS ADVANCES NOT REQUIRED
REUSABLE
STATION
OTHER
APPARATUS &
( Explain)
MATERIALS
EXEMPT MAT'L
SALVAGED
g
e
f

NET
ADVANCES
REQUIRED
h

TOTAL
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
INSPECTION - CERTIFICATION

NAME OF
BORROWER

I hereby certify that sufficient inspection has been made of the construction reported by this summary to give mereasonable assurance that the construction complies with
applicable specifications and standards and meets appropriatecode 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

ACCOUNTING VERIFICATION (RUS USE ONLY)
RUS FORM 771a

10-75

LICENSE NUMBER
SIGNATURE OF BORROWER'S STAFF ENGINEER