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Staudard Form 270 (cout'd)
<br />I cottify thrit to the best of ury IstioNvIctigo slid bolloftho data on the voyla so
<br />are ooiToot and that fill otitInyD ,veto made, In amixImloomIth The grant
<br />conditions or otheragreoloinn slid that plyinelit Is due, And has list been
<br />previously requested,
<br />`f1lis 61*60 for agency luo
<br />APPROWWORPAWFISIT. Convurt
<br />Approved.,
<br />AU17101UZED CERTIFYING CIPPICIAL DATE RRQUEST
<br />I SUBMITERI)
<br />WPM) OR PRINT13D NAME AM TITLr
<br />Diane Wilson
<br />and Adminlatrativo Offlou
<br />Polillp reporting burdon for this,00llootlon of InfiArnintion Is astimnied to avortigo 60 minutes per rosPoose, itichiding thurt for
<br />reviewing instructions, scotelthill Wathill, data sources, llatlio4ng and maintaining the dntla anoeded, ,and oomploting slid
<br />reviewing the collection ofillibriltation. Solid coulmouls regarding the burden Whiiate or my other aspect of this collection of
<br />laronnation. including Suggoslions for rothloing lilts burdall, to the offirte ofUhangotilont And Midget, Paperwork Redinction
<br />Project (0348. 0004), Washington, DC 20$03,
<br />PLFASP DO N HXTURN YOUR COMPLUED FORM TO THE OFFICE OF MANAC.FMrNT AND
<br />AGXNCY,-
<br />INSTRUCTIONS
<br />monae type or print legibly, Items 1, 3, 5,9, 10, 1 to, 1 lo, Ili, H&, Ill, 12 and 13 tile specific hisirmilolls for Other items Oro AS follows;
<br />2 indicate whether request is prepared Ott cash or ammod expeildiloro basis, All
<br />itiquests for Advances shall be prepared on it culi basis.
<br />4 Bitter-theFederal grant lislaor, Or Other idotit*lug itubiber assigned by lite Federal
<br />Jftivo advantio orrohoborsoment Is for more, thou one grant or
<br />othor agrooment, hisorl N/A; then, show site aggrogate. Amounts. Oil a separate sheet,
<br />list each grant ol- tigmemeat munborand the Podomi shore ofittutlays made Against site
<br />61slit or agreement.
<br />6 Enter tile employer Identification annibor milituid by AboUS. Internal 116voinfo
<br />Service, or th,5FICR (Jostilutim) utxlc. If roquostod by thoPoderal Agency.
<br />7 This space Is reserved for an vouctunt number o other idesitifying number that stay bo
<br />assigned by the rocipiouL
<br />a Hmer tile month, clay, anti -year for tile beginning and ending of tile perlod 00vortid In
<br />thisrequest. Jftllo requestit: for Bit Advance or for both all advance And
<br />CpIIt7bUY8PAralt, draw tine paritxl that fhs advmice and rainibm^soinatt, attest iho porkxf
<br />that like advance will cover. Into r"mi is show the period for
<br />-,vbtob the redlubumornout la requested. ,
<br />Note, Tho. Federal spoixorbig agonaies iunva t1m,opilon ofmquivingiroolplovita to complete.
<br />Itoins 11 or 12, but not both. -Item 12 should be used when only ativininyum amoinil of
<br />information Istioeded to make An Advance and outlay information contained In firm I I
<br />(,fill be,olitalned Ili atlovely limiler fivirl other reports
<br />11 111r purpose of the milbotlodlumns; (n), (1)), And (u) is to provide space. for separate
<br />cost breakdowns when a project lissbcan planned And bod[goted byprograin, i1mallon,
<br />orao(tvity,
<br />slid indicate. pAillo, number Ili space provided In upper right; however, the aninulary
<br />tonols of All prograins, or sothittlas slitimid be Amyn Ili the "total" column oil the firs(
<br />PROO,
<br />Ila Priter In "as of date,' the mo."di, day, and year of tile ending of1ho accounting
<br />period towhich this Asiouilt applies. - Enter program outlays to date (net of rolituida,
<br />robattia, find discounts), it% tile Appropriate colvinns. Por requoaht -prepared oil a
<br />oash basis, outlays pro (lie sUal of Actual cash rilsbutsements for goods Anil services,
<br />file Amount of In oXponstiis charged, tile Value of Ill-kind contributions applicd,
<br />mid (lie amount of oftols Advatlobstand pay,1111118 niado to sulicontraotors Alut
<br />subrPolpionts. For rquost prepared on an accrued expriulituro basis, oullqs Are
<br />(lie slun of (lie Actual OD411 dfsbnrsottlottts, (hemitinsit of indirect expenses Incurred,
<br />And The net Increase (of dooreaso) In tile Amounts owed by the recipient for goods
<br />and other property received And for services performed by insiploycesi contracts,
<br />OL-101
<br />TRUWRON131 (AREA
<br />C ODV,, 1\1 om at, it,
<br />stiblimatcos And payees.
<br />Ilb I'mor the cumulative cash Imorric received to date, It requests are prepared
<br />on a cash Willa, I lor rquoilt; prepared on all acerriod oxilondittiril basis,
<br />enter the olintrilitive Income earned to date, Under either WAS, enter only
<br />the ninowit applimble to progtom hicomo that Nvas required to be used for tho
<br />project or program by the terms of the grans or other Agreement.
<br />lid Only whou snaking requests for Advance payments. olitor 010 total wth"ated
<br />Amour of cash outlays flitit will be mado during the period covered by the
<br />advance,
<br />13 Complete the cortificatlantofore stibinitting this request.
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