Form BLR 05620 Invoice - Illinois

Form BLR05620 is a Illinois Department of Transportation form also known as the "Invoice". The latest edition of the form was released in October 16, 2018 and is available for digital filing.

Download a PDF version of the Form BLR05620 down below or find it on Illinois Department of Transportation Forms website.

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Invoice
Date
Payable To:
Local Public Agency
Payment Number
Final
Address
Obligation Number
State Job Number
Section Number
Agreement Date
Improvement Location
Improvement Description
Service Dates:
From
To
FHWA Authorization Date
Maximum Reimbursement
Previous Reimbursement
Total Costs Incurred on Invoice
Invoice Reimbursement Amount
District Local Roads and Streets Engineer
Date
Central Office Use Only
Approval Stamp
Funding Code
Function Code
Schedule No.
Engineer of Local Roads and Streets
Date
Printed 06/05/19
BLR 05620 (Rev. 10/16/18)
Invoice
Date
Payable To:
Local Public Agency
Payment Number
Final
Address
Obligation Number
State Job Number
Section Number
Agreement Date
Improvement Location
Improvement Description
Service Dates:
From
To
FHWA Authorization Date
Maximum Reimbursement
Previous Reimbursement
Total Costs Incurred on Invoice
Invoice Reimbursement Amount
District Local Roads and Streets Engineer
Date
Central Office Use Only
Approval Stamp
Funding Code
Function Code
Schedule No.
Engineer of Local Roads and Streets
Date
Printed 06/05/19
BLR 05620 (Rev. 10/16/18)
Instructions for BLR 05620
This form is to be used to request reimbursement of funds per an agreement with the Local Public Agency (LPA). Part of the information
required to complete this form will come from the approved agreement between the LPA and IDOT. If the invoice being processed
includes a final reimbursement for engineering, where the engineering also included work by a sub-consultant, then BLR 05613 must also
be completed prior to processing the reimbursement. For more information refer to the Bureau of Local Roads and Streets (BLRS) manual,
Chapter 5.
Date
Insert the date the invoice is being prepared.
Payable To
Insert the name of the Local Public Agency (LPA) as shown on the IDOT Agreement for this
project. Do not include name of individuals i.e. mayor, treasurer.
Address
Insert the address of the LPA. This is the address where the check will be mailed.
Payment Number
Insert the payment number for this invoice. If this is the final invoice check the box marked
final and that there is nothing outstanding. If final is checked verify with the LPA that this will
be the final invoice for this obligation number.
Obligation Number
Insert the obligation number assigned to this section and job number. The obligation number
can be found in the WMFT system. This field is for IDOT use only.
State Job No.
Insert the assigned state job number. This number can be found on the agreement form.
Section Number
Insert the section number as assigned. This number can be found on the agreement form
and in the WMFT System.
Agreement Date
Insert the date the agreement with the LPA was signed by IDOT.
Improvement Location
Insert the improvement location as stated on the approved agreement form.
Improvement Description
Insert the project description as stated on the approved agreement form.
Service Dates
Insert the beginning and ending dates of service for the invoice.
FHWA Authorization Date
Insert the date Federal Highway authorized the funds.
Maximum Reimbursement
Insert the maximum reimbursement as stated on the approved agreement. The maximum
reimbursement field is the upper limit of compensation. Please note that the actual maximum
reimbursement will be the lesser of one of the following:
a)
The upper limit noted on the approved agreement.
b)
The upper limit shown on the approval letter for the Local Public Agency-
Consultant agreement. Or,
c)
The federal share of construction engineering
If necessary, the maximum reimbursement will be adjusted accordingly.
Previous Reimbursement
Insert the sum of all amount previously reimbursed to the LPA for this section & job number.
Total Costs Incurred on Invoice
Insert the total amount of all expenses incurred by the LPA for the current services dates
period. Ensure the total amount of the invoice agrees with the supporting documentation and
that all expenses incurred and submitted for reimbursement do not differ from the scope of
services or direct costs approved by IDOT/CBLRS.
Invoice Reimbursement Amount
Insert the amount of funds for which reimbursement is being requested. This cannot exceed
the maximum reimbursement amount.
District Local Roads and Streets Engineer
Upon approval the IDOT District Local Roads and Streets Engineer will sign and date here.
Central Office Use Only
The fields below will be completed by the IDOT BLRS Central office staff.
Funding Code
Insert the funding code as it applies to this invoice.
Function Code
Insert the function code
Schedule No.
Insert the schedule number this invoice is being included in.
Approval Stamp
Stamp with the date received stamp.
Engineer of Local Roads and Streets
Upon approval the Engineer of Central Local Roads and Streets will sign here.
A minimum of two (2) signed originals must be submitted.
Distribution will be as follows:
District File
Bureau of Local Roads and Streets Central Office
Printed 06/05/19
BLR 05620 (Rev. 10/16/18)

Download Form BLR 05620 Invoice - Illinois

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