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1 cenjfy that to the best of my knowledge and belief the data - ne roverse arc ? SIGNATURE OF AUTHORfZED CERi ., . nVG OFFICIAL I DATE R£QU£ST
<br />co?rect and that all outlays were madc in accordance wiih the grant conditions or SUBMI7'fED
<br />other agreement and ihat payment is due and has not becn previously requested.
<br />This space for agency use
<br />7YPED OR PRINTED NAME ANU TITLE
<br />APPROVED FOR PAYMENT. Concur:
<br />Executive Diroctor
<br />TELEPHONE (AREA CODE,
<br />NUMBER, EXTENSlON)
<br />Approved:
<br />Gmnts and Cooperative Agrcements Officer's Tecfinical Repceuntative
<br />Public reporting burden for this collection of infortnation is estimated to average 60 minutes per response, including time for
<br />reviewing inshuctions, uarching existing data sources, gathering and maintaining the data needed, and completing and reviewing
<br />the wllection of infortnation. Send comments regarding the burden estimate or any othtt aspect ofthis collection of infortnation,
<br />including suggestions for reducing this burden, to the Office of Management and Budget, Papenvork Reduction Project (0348-
<br />0004), Washington, DC 20503.
<br />PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET,
<br />SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORiNC AGENCY.
<br />INSTRUCTIONS
<br />Please type or print legibly. Items 1, 3, 5, 9, 10, 1 lc, l le, ll f, l lg, ll i, 12 and 13 are selP-explanatory; specific instructions Por other items are as follows:
<br />llem Erurv and other propetty received and for services perfortned by employees, contracts,
<br />subgrantees and payces.
<br />2 Indicate whother request is prepared on cash or accrued expenditure basis. AN
<br />roquests for advances shall be prepared on a cash basis.
<br />4 Enter the Federal grant number, or other identifying number assigned by the Federal
<br />sponsoring agency. If the advance or reimbursement is for more than one grant or
<br />other agreement, insert N/A; then, show the aggregate amounts. On a separate sheet,
<br />list each grant or agreement number and the Federal share of outlays made against the
<br />grant or agreement.
<br />6 Enter the employer identification number assigned by the U.S. Intemal Revenue
<br />Service, or the FICE ([nstitution) code if requested by the Federa4 ageney.
<br />7 This space is reserved for an account number o other identifying number that may be
<br />assigned by the recipient.
<br />8 Enter the month, day, and yeaz for the beginning and ending of the period covered in
<br />this request. If the request is for an advance or for both an advance and
<br />reimbursement, show the period that the advance and reimbursement, show the period
<br />that the advance will cover. If the request is for reimbursement, show the period for
<br />which the reimbursement is requested.
<br />Note: 'Ihe Federal sponsoring agencies have the option of requiring recipients to complete
<br />items 11 or 12, but not both. Item 12 should be used when only a minimum amount
<br />of information is needed to make an advance and outlay information contained in item
<br />1 I can be obtained in a timely manner from other reports
<br />The purpose of the vertical wlumns (a), (b), and (c) is to provide space for separate
<br />cost breakdowns when a project has been planned and budgeted by program,
<br />fimction, or activity. If additional columns are needed, use as many additional fortns
<br />as needed and indicate page number in space provided in upper right however, the
<br />summary totals of all programs, or activities should be shown in the "total" column on
<br />the first page.
<br />11a Enter in "as of date," the month, day, and yeat of the ending of the accounting
<br />period [o which this amount applies. Enter program outlays to date (net of refunds,
<br />rebares, and discounts), in the appropriate columns. For requests prepared on a
<br />cash basis, outlays are the sum of actual cash disburscments for goods and services,
<br />the amount of indirect expenses charged, the value of in-kind contributions applied,
<br />and the amoun[ of cash advances and payments made to subcontractors and
<br />subrecipients. For request prepared on an accrued ezpenditure basis, ouUays are
<br />the sum of the actual cash disbursements, the amount of indirect expenses incurred,
<br />azd the net inerease (or decrease) in the amounts owed by the recipient for goods
<br />] lb Enter the cumulative cash income received to date, if requests are prepared on a
<br />cash basis. For requests prepared on an accrued expenditure basis, enter the
<br />cumulative income earned to date. Under either basis, enter only the amount
<br />applicab(e to program income that was required to 6e used for the project or
<br />program by the terms of the grant or other agreement.
<br />l ld Only when making requesa for advance payments, enter the [otal es[imated amoun[
<br />of cash outfays thac will be made during the period covered by the advance.
<br />13 Complete the cettification before submitting this request.
<br />Page 22 of 26
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