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ATTACHMENT II <br />Standard Form 270 <br />u. COMPUTATION OF AMOUNT OF REIMBURSEMENT /ADVANCES REQUESTED <br />(a) (b) (c) <br />PROGRAMS/FUNCTIONS ACTIVITIES <br />a. Total program (As of date) <br />outlays to day $ $ $ <br />L Less: Cumulative program income <br />c. Net program outlays (Line a minus line b) <br />d. Estimated net cash outlays for advance <br />e. Total (Sure of lines c,& d) <br />f. Non - Federal share of amount of line e <br />.g. Federal share of amount on line e <br />h. Federal payments previously requested <br />i. Federal share now requested (Line g <br />minus line h) <br />j. Advances required by 1st month <br />month, when requested by <br />Federal grantor agency for 2nd month <br />use in making <br />prescheduled advances 3rd month <br />12. ALTERNATE COMPUTATION FOR ADVANCES ONLY <br />a. Estimated Federal cash outlays that will be made during period covered by the advance $ <br />b. Less: Estimated balance of Federal cash on hand as of beginning of advance period <br />TOTAL <br />c. Amount requested (Linea minus tine b) $ <br />AUTHORIZED FOR LOCAL REPRODUCTION (Continued on Reverse) Standard Form 270 (Rev 2 -92) <br />Prescribed by Office of Management and Budget <br />Cir. No. A -102 and A -110 <br />Standard Form 270 (cont'd) <br />13. CERTIFICATION <br />Page 21 of 26 <br />OMB APPROVAL NO. <br />PAGE OF <br />REQUEST FOR ADVANCE <br />0348 -0004 <br />PAGES <br />OR REIMBURSEMENT. <br />1. TYPE OF PAYMENT <br />a. 'X" one or both boxes <br />BASIS OF REQUEST <br />REQUESTED <br />ADVANCE ❑ REIMBURSEMENT <br />❑ CASH <br />b. 'X" the applicable box <br />[J FINAL El PARTIAL <br />(See instructions on back) <br />ACCRUAL <br />3. FEDERAL SPONSORING AGENCY AND ORGANIZATION ELEMENT <br />4. FEDERAL GRANTOR OTHER IDENTIFYING NUMBER <br />5. PARTIAL PAYMENT <br />TO WHICH THIS REPORT IS SUBMITTED <br />ASSIGNED BY FEDERAL AGENCY <br />REQUEST NUMBER FOR <br />THIS REQUEST <br />6. EMPLOYER IDENTIFICATION <br />7. RECIPIENTS ACCOUNT <br />8, PERIOD COVERED BY THIS REQUEST <br />NUMBER <br />NUMBER OR <br />IDENTIFYING NUMBER <br />FROM (month, day, year) <br />TO (month, day, year) <br />9. RECIPIENT ORGANIZATION <br />10. PAYEE (Where check is to be sent if different thatt item 9) <br />Nante <br />Name <br />Number <br />Number <br />and Street <br />and Street <br />City, State <br />City, State <br />and ZIP Code <br />and ZIP Code <br />u. COMPUTATION OF AMOUNT OF REIMBURSEMENT /ADVANCES REQUESTED <br />(a) (b) (c) <br />PROGRAMS/FUNCTIONS ACTIVITIES <br />a. Total program (As of date) <br />outlays to day $ $ $ <br />L Less: Cumulative program income <br />c. Net program outlays (Line a minus line b) <br />d. Estimated net cash outlays for advance <br />e. Total (Sure of lines c,& d) <br />f. Non - Federal share of amount of line e <br />.g. Federal share of amount on line e <br />h. Federal payments previously requested <br />i. Federal share now requested (Line g <br />minus line h) <br />j. Advances required by 1st month <br />month, when requested by <br />Federal grantor agency for 2nd month <br />use in making <br />prescheduled advances 3rd month <br />12. ALTERNATE COMPUTATION FOR ADVANCES ONLY <br />a. Estimated Federal cash outlays that will be made during period covered by the advance $ <br />b. Less: Estimated balance of Federal cash on hand as of beginning of advance period <br />TOTAL <br />c. Amount requested (Linea minus tine b) $ <br />AUTHORIZED FOR LOCAL REPRODUCTION (Continued on Reverse) Standard Form 270 (Rev 2 -92) <br />Prescribed by Office of Management and Budget <br />Cir. No. A -102 and A -110 <br />Standard Form 270 (cont'd) <br />13. CERTIFICATION <br />Page 21 of 26 <br />