Transcription of 0348-0004 REQUEST FOR ADVANCE OR REIMBURSEMENT …
1 OMB APPROVAL NO. PAGEOF0348-0004 PAGES a. "X" one or both boxes2. BASIS OF REQUEST 1. TYPE OF PAYMENTb. "X" the applicable box(See instructions on back) REQUESTED3. FEDERAL SPONSORING AGENCY AND ORGANIZATIONAL ELEMENT TO4. FEDERAL GRANT OR OTHER5. PARTIAL PAYMENT REQUEST WHICH THIS REPORT IS SUBMITTED IDENTIFYING NUMBER ASSIGNED NUMBER FOR THIS REQUEST BY FEDERAL AGENCY6. EMPLOYER IDENTIFICATION7. RECIPIENT'S ACCOUNT COVERED BY THIS REQUEST NUMBER OR IDENTIFYING NUMBERFROM (month, day, year)TO (month, day, year)9. RECIPIENT ORGANIZATION10. PAYEE (Where check is to be sent if different than item 9)Name:Name:NumberNumberand Street:and Street:City, StateCity, Stateand ZIP Code:and ZIP OF AMOUNT OF REIMBURSEMENTS/ADVANCES REQUESTEDPROGRAMS/FUNCTIONS/ACTIVITIESa.
2 Total program(As of date) outlays to dateb. Less: Cumulative program incomec. Net program outlays (Line a minus line b)d. Estimated net cash outlays for ADVANCE periode. Total (Sum of lines c & d)f. Non-Federal share of amount on line eg. Federal share of amount on line eh. Federal payments previously requestedi. Federal share now requested (Line g minus line h)j. 1st month 2nd month 3rd COMPUTATION FOR ADVANCES ONLYa. Estimated Federal cash outlays that will be made during period covered by the ADVANCE $b. Less: Estimated balance of Federal cash on hand as of beginning of ADVANCE periodc. Amount requested (Line a minus line b)$AUTHORIZED FOR LOCAL REPRODUCTION(Continued on Reverse)STANDARD FORM 270 (Rev. 7-97)Prescribed by OMB Circulars A-102 and A-110 REQUEST FOR ADVANCEOR REIMBURSEMENTADVANCEFINALPARTIALCASHACCR UALREIMBURSE-MENTA dvancesrequiredbymonth, when requestedbyFederalgrantoragency for use in makingprescheduled advancesTOTAL$$$$(a)(c)(b) OR AUTHORIZED CERTIFYING OFFICIALDATE REQUESTSUBMITTEDTYPED OR PRINTED NAME AND TITLETELEPHONE (AREACODE, NUMBER,EXTENSION)This space for agency useINSTRUCTIONSP lease type or print legibly.
3 Items 1, 3, 5, 9, 10, 11e, 11f, 11g, 11i, 12 and 13 are self-explanatory; specificinstructions for other items are as follows:ItemEntryItemEntrySTANDARD FORM 270 (Rev. 7-97) BackIcertifythattothebestofmyknowledgean dbeliefthedataonthereversearecorrectandt hatalloutlaysweremadeinaccordancewiththe grantconditionsorotheragreementandthatpa ymentisdueandhasnotbeen previously ,includingtimeforreviewinginstructions,s earchingexistingdatasources,gatheringand maintainingthedataneeded, ,includingsuggestionsforreducingthisburd en,totheOfficeofManagementandBudget,Pape rworkReduction Project ( 0348-0004 ), Washington, DC BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING on a cash , ,insertN/A;then, ,listeachgrantoragreementnumberandtheFed eralshareofoutlaysmade against the grant or ,ortheFICE(institution)code if requested by the Federal number that may be assigned by the ,day, , ,showtheperiod for which the REIMBURSEMENT is , information contained in item 11 can be obtained in a timely manner from other (a),(b),and(c)istoprovidespaceforseparat ecostbreakdownswhenaprojecthasbeenplanne dandbudgetedbyprogram,function, ,useasmanyadditionalformsasneededandindi catepagenumberinspaceprovidedinupperrigh t.
4 However,thesummarytotalsofallprograms,fu nctions,oractivitiesshouldbeshown in the "total" column on the first "asofdate,"themonth,day, (netofrefunds,rebates,anddiscounts), ,outlaysarethesumofactualcashdisbursemen tsforgoodsandservices,theamountofindirec texpensescharged,thevalueofin-kindcontri butionsapplied, ,outlaysarethesumoftheactualcashdisburse ments,theamountofindirectexpensesincurre d,andthenetincrease(ordecrease)intheamou ntsowedbytherecipientforgoodsandotherpro pertyreceivedandforservicesperformedbyem ployees, contracts, subgrantees and other , , ,enteronlytheamountapplicabletoprogramin comethatwasrequiredtobeusedfortheproject orprogrambythe terms of the grant or other ,enterthetotalestimatedamountofcashoutla ysthatwillbe made during the period covered by the the certification before submitting this :1111a11b11d13
