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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 <br />Page 22 of 26 <br />