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' I :cr1iiy that to the bcst of m.• knowIedEe and bcGe(t(te data on the rcvcrce arc ? SfGNATURc OF AUTHORIZGD CERTIFI'ING OFFICIAL I DATE REQUEST <br />c)rtcct and that all outloys wore made in accordance ik-ith the gront condi?ions or SUBMfl"iED <br />other apreemcni and that payment is duc and has not been prc??iously rcquestcd. <br />TYPED OR PRIN7ED NAME AND TITLE <br />7ELEPHONE(AREA CODE. <br />NUT.ffiEA, EXTENSION) <br />This spacc (or agcncy usc <br />APPRON'ED FOR PAYNtEKT. Concur. <br />Executive Direcmr <br />Aprrovtd: <br />_ Gnnts and Cooperetive Agreemcnts OfTittr's Technical Represrnca[ive I <br />Public rcponing burdcn for this collection of infortnation iz estimated to avcnge 60 minutes pcr response, including time for <br />reviewing inscructions, scarching cxisting data.sourccs, gatheting and majntaining the data nccded, and completing and reviewing <br />the collection of information. Send comments regardingthe burdcn estimate or any other aspect ofthis eollcetion of in(ortnation, <br />including suggestions for reducing Ihis burden, to the Office of Managemcnt and Budgct, Paperworl: Reduetion Roject (0346• <br />0004), Washington, DC 20503. <br />PLEASE DO NOT RETURN 1'OUR COMPLETED FORM TO THE OFFICE OF MANACEA1Eh'T AND BUDCET, <br />SEND fT TO ?f{E ADDRESS PROVIDED Bl' THE SPOIVSORINC AGENCY. <br />iNSTRUCTIONS <br />Plcasc rype or print Icgibly. ]tcros I, 1, 5, 9, )0, I I c, 11e, I1 f,, 1 ig, 1]i, 12 and 13 are self-explanatory; sycciGc instrvetions for other items are u(ollows: <br />lrcnr F.ninand other propcrty rcceived and for serviees perfortncd by employecs, contracu, <br />. subgrantecs and piyecs. <br />I lndicatc wAahcr requcst is prepared on cash or aeerued expenditure basis. A11 <br />«quescs (or advances shall ba prcparcd on a cash basis. <br />4 Enter the Fedara! grani number, or other ideniifying numbcr assigned by the Fcdcral <br />zponsoring ageney. )t the advance or reimbursement is for more than onc gnnt or <br />other_agreemrnt, inten N/A; thcn, show the aggregate amounts. On a separate sheot, <br />list caeh gram or agreemcnt number and the Fedccalsharc of GuUayz made against the <br />gnnt or aFreement. <br />l ib Entcr the cumulative ush ineome reeeived t0 dalt, if fequests arc prcpared on a <br />euh Easis. For requcses preparcd on an acerued ezpenditure basis, emcr ihc <br />eumulative income urned to date. Undcr cither basis, eneer only the amourn <br />applicabic to progrun income that was requircd to bc used for Nc projcci or <br />program by the terms of the gnnt or oLher agreement. <br />I ld Oniy whcn making rcqucsu for advanec yaymonts, entor Nc toul estimaied nmo <br />of cash outlays thx will bc made during the pcriod covcre4 by the advancc. <br />6 Eneer the employer identi(cuion numbcr assiFned by the U.S. lntemal Revenue <br />Serviec, or the FICE (lnstituiion) code if requcsted by the Fcderal agcncy. <br />7 This space is rescrved for an account number o other identifying number thai may bc <br />azsigned by the reeipient. <br />8 Enter the month, day, and year for thc beginning and ending of the period eovered in <br />this requesi. 1( the request is !or an advance or for both an advanec and <br />reimbursrment, show the period thal the advance and reimbursemen4 sho..• the period <br />that the advancc wiU cover. If the tequcst is Cor reimburscmcnt, show the period for <br />which the reimbursement is requestcd. <br />2+loie: The Federal sponsoring agcncies havc tlu option of requiring recipients 1o eompleic <br />items I 1 or 12, bui noi bolh. litm 12 should be used when only a minimum amount <br />of information is needed to make an advancc and outla?• information contained in iitm <br />11 can be obtained in a timely manner from oiher rtpons <br />1! The puryose of the venical eolumns (a), (b), and (c) is to providc Spaec for separatc <br />eosi breakdowns when a ptoien nas bccn planned and budEeted by program. <br />function, or aetiviR•. !f additional eolumns are necded, use as many, additional fortns <br />aa nceded and indicam page number in space provided in upper riFht: hoN•ever. the <br />summan• totals of all programs, or actlvilics sliouid bc shown in the "total" column on <br />the first page. <br />113 Enier in 'ac o( date,' the monih, day, and year of dic anding of ihe zccouncing <br />period io which Lhis amouni applies. Erner prognm ouiiaqs io date (net of rcfunds, <br />tcb2ies, and diseounts), in thc appronriaie columns. For rcquesu prepared on a <br />ash basis, outbys ue Uie sum of acwal ush disbursemenu for goods and services, <br />the amoum ot indireet cznenses ehusuf, dx value of in-kind eontributi0ns zpplitd. <br />and the amouni of cash advances ind payments madc io subconiractors and <br />subrccipicnu. For tequest prcparcd on an accrucd czpendiwrc Dasis, outlays arc <br />the sum of the aceuai cash disburscmcros, thc amount of indirect expenses incurrcd. <br />---- . ... ..- --?.......? i?. enMc <br />13 Complete the cenibcation bcfore submie[ing this rcquest.