' 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.
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