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OOQ2~c 2 INSTRUCTIONS FOR PREPARING THE OUTLAY REPORT AND REQUEST FOR REIMBURSEMENT FOR CONSTRUCTION PROGRAMS Item 1 - Enter name of the Federal grantor agency and organizational element to which the report is submitted. Item 2 - Enter the grant number or other identifying num. ber assigned by the Federal grantor agency. Item 3 - Mark the appropriate box. If the request is final, the amounts billed should represent the final cost of the project. Item 4 - Show .....hether amounts are computed on an ac. crued expenditure or cash disbursement basis. Item 5 - Enter the partial payment request number. 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 for which this report is prepared. Item 9 - Enter the name and complete mailing address in. c1uding ZIP Code tor the grantee organization. Item 10 - Enter the name and complete mailing address inchx:ling the 21 P Code were the check should be sent, if the payee is different than the grantee organization shown in Item 9. PLEASE READ BEFORE COMPLETING ITEM 11 - The purpose of vertical columns (1) through (3) is to provide space for separate cost breakdowns when a large project has been planned and budgeted by program, function and activo ity. If additional columns are needed, use as many addi. tional forms as needed and mark "continuation" on each form; however, the summary totals of all programs. func. tions, or activities should be shown in the "lOtal" column on the first page. Item ,,- STA.TUS OF FUNDS - All amount!. are re- ported on a cumulative basis. Line a. Enter amounts expended for such items as travel. legal fees, rental of vehicles and any other administrative expenses. Include the amount of interest expense when authorized by program legislation. Also show the amount of interest expense on a separate sheet. Line b. Enter amounts pertaining to the work of locating and designing, making surveys and maps, sinking test ho.les, and alt other work required prior to actual con. struction. Line c. Enter all amounts directly associated with the acquisition of land, existing structures and related right- of.way. Line d. Enter basic fees for services of architectural en- gineers. Line e. Enter other architectural engineering services. Do not include any amounts shown on Line d. Line f. Enter inspection and audit fees of construction and related programs. Line g. Enter all amounts associated with the develop- ment of land where the primary purpose of the grant is land improvement. The amount pertaining to land devel- opment normally associsted with major construction should be excluded from this category and entered on Line k. Line h. Enter the dollar amounts used to provide reloca- tion advisory assistance and net costs of replacement housing (last resort). Do no! include amounts needed for relocation adminis.r:rative expense; these amounts should be included in amounts shown on Line a. Line i. Enter the amount of relocation payments made by the grantee to displaced persons, farms, business con- cerns, and nonprofit organizations. Line j. Enter gross salaries and wages of employees of the grantee and payments to third party contractors directly engaged in performing demolition or removal of struc- tures from developed land. All proceeds from the sale of salvage or the removal of structures should be credited to this account; thereby reflecting net amounts if required by the grantor agency. line k. Enter those amounts associated with the actual construction of, addition to, or restoration of a facility. Also include in this category the amounts for project im- provements such as sewers. streets, landscaping, and lighting. line I. Enter amounts for all equipment, both fixed and movable, exclusive of equipment used for construction. For example. permanently attached laboratory tables, built-in audio visual systems, movable desks, chairs, and laboratory equipment. line m. Enter the amounts for all items not specifically mentioned above. Line n. Enter the total cumulative amount to date which should be the sum of Lines a through m. line o. Enter the total amount of program income ap- plied to the grant except income included on Line j. Iden- tify on a separate sheet of paper the sources and types of the income. Line p. Enter the net cumulative amount to date which should be the amount shown on Line n minus the amount on Line O. Line q. Enter the Federal share of the amount shown on Line p. line r. Enter the amount of rehabilitation grant pay. ments made to individuals when program legislation pro- vides 100 percent payment by the Federal grantor agency. Line S. Enter the total of Lines q and r. Line 1. Enter the total amount of Federal payments pre- viously requested, if this form is used for requesting reim- bursement. Line U. Enter the amount now being requested for reim- bursement. This amount should be the difference be- tween the amounts shown on lines sand t. If different, explain on a separate sheet. Line V. Show the percentage of the physical completion of the project. Item 12 - CERTI FICATION a GRANTEE - Enter the name, title, telephone number, and signature of the grantee official who is responsible for the operation of the program. The date should be the actual date the form is submitted to the Federal grantor agency. b. STATE, LOCAL, OR FEDERAL GOVERNMENT REPRESENTATIVE - Enter the name, title, telephone number, and signature of the Government representative who is certifying to the percent of project completion. This representative may be a professional architectural engineer, under contract to the State, local, or Federal government or he may be a qualified State, local. or Federal government employee.