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<br />' t cehjE;' that 10 Ihc beif o(m)' 1:no%vdeditc and Sclief ihe dua on the rcycrap ote SIGN147URE Oi AUTIIGRIZED CERTIFYlNG OG'FIClw4
<br />romc;snd that ait outltys were mads in ucmdantc wifi ifie 1;nni condilims or
<br />pther agrcemen: artd thsl psyment is duc and has nat be:n previausly teqvetted.
<br />TYP50 OR FRlNTED NAMH ANp TlTtE
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<br />O,tTE REOI,'£ST
<br />Stf9MtT7ED
<br />i ELEPHQN'E(AREA CQDE.
<br />NLIMBER. EX7'ENS10N)
<br />This spaee (or a ffency ulitt APPAOV£D FOA PAl'MEri"f. Concur:
<br />f.xaut;vc Dlrectar
<br />Approred: '
<br />Gnms amd Ceopentive Agttements Officer's Technienl Reprcsenqtive
<br />?
<br />Public rcponing bardrn !or this copeaion ot intom?:tion is es(imattd Io avenge 60 miautu per rcsponst, iadudin= lime for
<br />?reviewirt insnuotions, seuching exisiinp data.saurocs, ptbeting and munuinins the dau naded, ard wmple+in j andrcviewine
<br />the col?ccuan of intom+.uon. S.nd comments rcgvdins the burdm ettimate or iny otha ispeca of thi: eoileetion of informfiion,
<br />ineludinp sugtottions tor teducinQ, this burAen, to the OtTiee oCManigement 2-44 Budga, Papenrcrfc Reduuian Projrn (0344.
<br />4004), Washington, DC 20503.
<br />P1.EASEAO NQT RETURN YOUA COMPLETEA FORM TO'T'HE OFFiGE OF MAPtACEMEN7AND SUDGET,
<br />SEND 1T TO 7HE ADDAES5 PRDYIDED 8Y THE SPOI`ISORINC ACENCY.
<br />INSTRUC?l ONS
<br />Ylease rype or print legibiy, itcros I, 3,5,9, 10, ! 1 e, l) e, 1 f f,, t I t, 111, 12 snd 13 uo se1!-explamtary; tpeeiGc insuuaions [or other iiems uo at follows:
<br />lren, frun? ud other propeRy teuived tt+d tot urvua perfomzd by uraployeu, eamnci
<br />srbPramees sM psyees.
<br />] lndie:tc svhetAu rcquezt is prcparcd en eash or u;tved ezprndiwn buis. All
<br />requests.tor advanea shall oe preparcd on a eash buis.
<br />1 Enterihe Federai gwt number, or nt6er idrntifying numbcr assigneQ by the Fadcnl
<br />spontoring s;anry, tf the advsnee orreimburscment is (ar more thtn ons grant or
<br />othac ogreemsnt.+nun N/A; iheq, sbow the abEngaEc amounts, 4n a scysnte shect,
<br />list eath grant ot agrcemcni numba znd the Federa! sh&rc of sWttays made All'tnsl lhe
<br />gnnt er agreesnent.
<br />6 Eneu the emp{oynr idrnliGcation nunbt: usip+ed by the U.5.lntemil Revenue
<br />Serviec, or Q+a FICE (instimdan) codc if rcquested by tRa Fedcnl igrncy.
<br />7 7his zuo is t+eseeved for an aceount aumber o other ideatifyinr number that mty be
<br />as3igned by the rceip+ent.
<br />8 Enier the month, dap, and Yeu far lhe beQinnint snd ending of the pcriod covercd fin
<br />this reqneu. lf thc roquen is !w an sdvaner or tot bo1A an advanee and
<br />reimtursomrn4 srow the xriod lhat the advance and re+mbunement, show !hc perioc
<br />that the advance wiA cover. !I'the rcquest is for ttimbu•semrn6 ahow the pcnod tor
<br />whieb the rcimbursement is requesled.
<br />Noee: '11rc Fedaal sponsonng %Fu+eiot hrie the option of «quirint neipirnts to eampfete
<br />itemi 11 or 12, but nm both. Itan 12 should bc nsed uten only a minimum amount
<br />of intomuuoa is necded a mikt en advmee and oW1:Y iniannatioo eoatsined in i1cm
<br />1 I eun 6e obuined in a timeiy manner frorn rnha seDons ,
<br />! i 7he avtpese af !hc vsrt'stol columns (a), (b), ind (c) is io providr spuc for sepantc
<br />eost bcutidowns wh:n a ?ro;ea has becn planneQ and budFeicd dy provam,
<br />iunaion, or aeiiviry. 1f otld'ttional aolumes are needed, use u many additionnt forms
<br />as needed and indlcue -,s;e number in space pravidcd in upper right; howeva, slie
<br />summax, iou1s olaU prognms, a aurvi(ias s1+euld be shown in cAc "wtaP column on
<br />the first papa.
<br />11o fmcr m'aF of auc.' Qx momh. 63y. and yeir o( tlu ending of Lne ucwruinp
<br />peticd ro which Jttf unourta spDEias. flrnrt pralnm awt:,•s w da+e (ixi pt rcluads.
<br />rtbnu. lntf Ciseaums). +n Oe apptoprmtc cotuenns. For ret}uuu pteputC on o
<br />sasb buis. piA:ays arc the sum ot au4a1 cash distrurumrna !ar toodf and serriea,
<br />the artqum et initirm scpcnscs clarred. tJ?e vsfue o' in.kind caruributiona aPOIicA,
<br />-^" .- --a ?r -, ,n.anees and nsvmerus made ~o subeontraMan ind
<br />r ?
<br />l lb Emet ihe wmutative uth income teeeivcd 4o doto, if requcsu arc prcpxred or
<br />cuh 6uis. For regaeses prepired on in actrved c;Drndieurc buis, cnier the
<br />eumulaave ineome amed co doce, Unda cither basi:, ente• anly the smount
<br />appliuble to pmrnm incomr thai was rc4uired to be usod !or the projeci or
<br />protrun by t2te tectns of the rnm ot othet atreement.
<br />11d Only wArn makint raqucsu (or advanu paymenu, emet the total utimucd an
<br />of cath ot,tliys dut wip be msde dutinj the period eovered by the advaacc.
<br />13 Complae The cenif+acion bclore subm8eing thls raquess.
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