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000244 2 INSTRUCTIONS FOR PREPARING THE REQUEST FOR ADVANCE OR REIMBURSEMENT Item 1 - Enter the name of the Federal grantor agency and organizational element to which the request is submitted. Item 2 - Enter the Federal grant number or other identi- fying number assigned by the Federal gran~or agency. Item 3 - Indicate with an "X" whether the type of pay- ment requested is: a. An advance, reimbursement, or both. b. Final or partiaL Item 4 - Indicate with an "X" whether the report is pre. pared on a cash or accrued expenditure basis. All requests which are for advances only shall be prepared on a cash basis. Item 5 - Enter the partial payment request number for this request. Item 6 - Enter the employer identification number as- signed by the U. S. Internal Revenue Service. Item 7 - This space is reserved for an account number or other identifying number which may be assigned by the grantee. Item 8 - Enter the month, day, and year for the beginning and ending of the period covered in this request. It the request is tor an advance or tor both an advance and reim- bursement, show the period that the advance will cover. If the request is for a reimbursement, show the period for which the reimbursement is requested. Item 9 - Enter the name and complete mailing address, including ZI P Code for the grantee organization. Item 10 - Enter the name and complete mailing address, including Z\P Code of the payee if it is different than the grantee organization shown in Item 9. PLEASE READ BEFORE COMPLETING ITEM 11 - The purpose of the vertical Columns (ll through (3) is to pro- vide space for separate cost breakdowns when a large project has been planned and budgeted by program, func. tion, and activity. If additional columns are needed, use as many additional forms as needed and mark "continuation" on each form; however, the summary totals of all programs, functions, or activities should be shown in the "total" Col. umn on the first page. Item 11 - COMPUTATION OF AMOUNT REQUESTED. Line a - On the stub enter the month. day, and year of the ending of the accounting period to which this amount applies. Enter program outlays to date in the appropriate columns. For reports which are prepared on a cash basis. outlays are the sum of actual cash disbursements for goods and services. the amount of indirect expenses charged, the value of in-kind contributions applied, and the amount of cash advances and payments made to sub. contractors and subgrantees. For reports prepared on an accrued expenditure basis, outlays are the sum of the actual cash disbursements, the amount of indirect ex. penses incurred, the value of in-kind contributions ap. plied, amounts owed by the grantee for goods and other property received, amount'S owed for services performed by employees, contractors, subgrantees, and other payees, and amounts becoming owed for which no current service or performance is required. line b - Enter the cumulative cash income received to. date, if reports are prepared on a cash basis. For reports prepared on an accrued expenditure basis, enter the cumulative income earned to date. Under either basis, enter only the amount applicable to program income which was required to be used for the project or program by the terms of the grant. Line c - This amount should be the difference between the amounts shown on Line a less the amounts shown on line b. Line d - Only when making requests for advance pay- ments, enter the total estimated amount of cash outlays that will be made during the period covered by the ad- vance. Line e - Enter the total of Lines c and d. Line f - Enter the non.Federal share of the amount shown on Line e. Line g - Enter the Federal share of the amount shown on Line e. Line h - Enter the cumulative amount of Federal pay- ments received and amounts included in outstanding re- quests. Line i-Enter the Federal share now requested. (Line g minus Line h). Line j - Show the amount of advances required by month on each of Lines (11, (2), and (3) when requested by the Federal grantor agency for use in making pre- scheduled advances. Item 12 - This space is provided for any explanation deemed necessary by the grantee and for any information required by the Federal grantor agency in compliance with the governing legislation. Item 13 - Complete the certification before submitting this report.