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1 ceRify that to the best of my knowledge and belief the data on the reverse are l SIGNATURE OF AUTHORIZED CERTIFI'ING OFFIC[AL I DATE REQUEST
<br />cornct and that all ouAays were made in accordance with the gant conditions or I SUBMI"fTED
<br />R other agreement and that payment is due and has not been previou5ly requested.
<br />TYPED OR PRINTED NAME AND TITLE
<br />1'his space for agency use
<br />APPROVED FOR PAYMENT. Concur:
<br />Executive Director
<br />TELEPHONE (AREA CODE,
<br />NUMBER, EXTENSION)
<br />Approved:
<br />Gnnts and Cooperative Agreements Officer's Technical Repmsentative
<br />Public reporting buuden for this collection of information is estimated to average 60 minutes per response, including time for
<br />reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and cortipleting and reviewing
<br />the collection of information. Send connnents regarding ihe burden estimate or any other aspect of this collection of infomiation,
<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 APiD BUDCET,
<br />SEND [T TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
<br />INSTRUCTIONS
<br />Please type or print legi'bly. Items 1, 3, 5, 9, 10, 11 c, 1 I e, I 1 f, 11 g, 11 i, 12 and 13 are self-explanatory; specific instructions for other items are as follows:
<br />Item Entrv applicable to program income that was required to be used for the project or
<br />program by the terms of the grant or other agreement.
<br />2 Indicate whether request is prepared on cash or accrued expenditure basis. All
<br />requests for advances shall be prepared on a cash basis. ] ld Orily when making requests for advance payments, enter the total estimated amount
<br />of cash outlays that will be made during the period covered by the advance.
<br />4 Enter the Federal grant number, or other identifying ninnber assigned by the Federal
<br />sponsoring agency. If the advance or reimbursement is for more than one gant or 13 Complere the certifica[ion before submitting [his request.
<br />other agreemeny 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 (Institution) code if requested by the Federal agency.
<br />7 This space is reserved for an account number o other identifying nucnher that may be
<br />assigned by the recipient.
<br />S Enter the month, day, and year 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 reimbursemen4 show the period for
<br />which the reimbursement is requested.
<br />Note: The Federal sponsoring agencies have the option of requiring recipients to complete
<br />items 1 I or 12, but not both. Item ] 2 should be used when only a rrrinimum amount of
<br />information is needed W make an advance and outlay information contained in item 11
<br />can be obtained in a timely manner from other reports
<br />11 The purpose of the vertical colunms (a), (b), and (c) is to provide space for separate
<br />cost breakdowns when a project has been planned and budgeted by program, function,
<br />or activity. If additional colunms are needed, use as many aciditional fornts as needed
<br />and indicate page number in space provided in upper right; however, the swrmary
<br />totals of all prograrru, or activities should be shown in the "total" colwrm on the first
<br />page.
<br />lla Enter in "as of date," the month, day, azd year of the ending of the accounting
<br />period to which this amount applies. Enter program outlays to date (cet of refunds,
<br />rebates, and discounts), in the appropriate columns. For requests prepared on a
<br />cash basis, outlays aze the sum of actual cash disbursements for goods and services,
<br />the amount of indirect expenses charged, the value of in-kind contributions applied,
<br />and the amount of cash advances and paymeats made to subcontractors and
<br />subrecipients. For request prepazed on an accrued expendimre basis, outlays are
<br />the sum of the actual cash disbursements, the amount of indirect expenses incurred,
<br />and the net increase (or decrease) in the amounts owed by the recipient for goods
<br />and other property received and for services performed by employees, contracts,
<br />subgrantees arxi payees.
<br />l 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 eamed to date. Under either basis, ent°r only the amount
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