I certify that to the best of my knowledge and belief the data me reverse are . I SIGNATURE OF AUTHORIZED CERT , NG OFFICIAL I DATE REQUEST
<br />or
<br />correct and that all outlays were made in accordance with the grant conditions SUBMITTED
<br />other agreement and [fiat payment is due and has not been previously requested.
<br />This space for agency use
<br />APPROVED FOR PAYMENT. Concur:
<br />TYPED OR PRINTED NAME AND TITLE
<br />Executive Director
<br />Approved:
<br />Grants and Cooperative Agreements Officer's Technical Representative
<br />Public reporting burden 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 completing and reviewing
<br />the collection ofinformation. Send comments regarding the burden estimate or any otheraspect of this collection of information,
<br />including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork 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 SPONSORING AGENCY.
<br />INSTRUCTIONS
<br />TELEPHONE (AREA CODE,
<br />NUMBER, EXTENSION)
<br />Please type or print legibly. Items 1, 3, 5, 9, 10, 11c, 1 le, I If, I Ig, I Ii, 12 and 13 are self - explanatory; specific instructions for other items are as follows:
<br />Irenr Entry
<br />and other property received and for services performed by employees, contracts,
<br />subgrantees and payees.
<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.
<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 />4 Enter the Federal grant number, or other identifying number assigned by the Federal
<br />cumulative income earned to date. Under either basis, enter only the amount
<br />sponsoring agency. If the advance or reimbursement is for more than one grantor
<br />applicable to program income that was required to be used for the project or
<br />other agreement, insert N /A; then, show the aggregate amounts. On a separate sheet,
<br />program by the terms of the grant or other agreement.
<br />list each grant or agreement number and the Federal share of outlays made against the
<br />grant or agreement.
<br />l ld Only 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 />Enter the employer identification number assigned by the U.S. Internal Revenue
<br />Service, or the F10E (Institution) code if requested by the Federal agency.
<br />13 Complete the certification before submitting this request.
<br />This space is reserved for an account number o other identifying number that may be
<br />assigned by the recipient.
<br />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 reimbursement, show the period for
<br />which the reimbursement is requested.
<br />Note: The Federal sponsoring agencies have the option ofrequiring recipients to complete
<br />items 1 I 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 />11 can be obtained in a timely manner from other reports
<br />The purpose of the vertical columns (a), (b), and (c) is to provide space for separate
<br />cost breakdowns when a project has been planned acid budgeted by program,
<br />function, or activity. If additional columns are needed, use as many additional forms
<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 />I la Enter in "as of date," the month, day, and year of the ending of the accounting
<br />period to which this amount applies. Enter program outlays to date (net of refunds,
<br />rebates, and discounts), in the appropriate columns. For requests prepared on a
<br />cash basis, outlays are 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 />40and the amount of cash advances and payments made to subcontractors and
<br />subrecipients. For request prepared on an accrued expenditure 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
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