Attachment C - SF-270.pdf

OMB APPROVAL NO. PAGE OF

0348-0004 PAGES

a. "X" one or both boxes 2. BASIS OF REQUEST

1.

TYPE OF

PAYMENT b. "X" the applicable box

(See instructions on back) REQUESTED

3. FEDERAL SPONSORING AGENCY AND ORGANIZATIONAL ELEMENT TO 4. FEDERAL GRANT OR OTHER 5. PARTIAL PAYMENT REQUEST

WHICH THIS REPORT IS SUBMITTED IDENTIFYING NUMBER ASSIGNED NUMBER FOR THIS REQUEST

BY FEDERAL AGENCY

6. EMPLOYER IDENTIFICATION 7. RECIPIENT'S ACCOUNT NUMBER 8. PERIOD COVERED BY THIS REQUEST

NUMBER OR IDENTIFYING NUMBER FROM (month, day, year) TO (month, day, year)

9. RECIPIENT ORGANIZATION 10. PAYEE (Where check is to be sent if different than item 9)

Name: Name:

Number Number and Street: and Street:

City, State City, State and ZIP Code: and ZIP Code:

11. COMPUTATION OF AMOUNT OF REIMBURSEMENTS/ADVANCES REQUESTED

PROGRAMS/FUNCTIONS/ACTIVITIES

a. Total program (As of date) outlays to date

b. Less: Cumulative program income

c. Net program outlays (Line a minus line b)

d. Estimated net cash outlays for advance period

e. Total (Sum of lines c & d)

f. Non-Federal share of amount on line e

g. Federal share of amount on line e

h. Federal payments previously requested

i. Federal share now requested (Line g minus line h) j.

1st month

2nd month

3rd month

12. ALTERNATE COMPUTATION FOR ADVANCES ONLY

a. 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 period

c. 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 ADVANCE

OR REIMBURSEMENT ADVANCE

FINAL PARTIAL

CASH

ACCRUAL

REIMBURSE-

MENT

Advances required by month, when requested by Federal grantor agency for use in making prescheduled advances

TOTAL

(a) (c)(b)

13. CERTIFICATION

SIGNATURE OR AUTHORIZED CERTIFYING OFFICIAL DATE REQUEST

SUBMITTED

TYPED OR PRINTED NAME AND TITLE TELEPHONE (AREA

CODE, NUMBER,

EXTENSION)

This space for agency use

INSTRUCTIONS

Please type or print legibly. Items 1, 3, 5, 9, 10, 11e, 11f, 11g, 11i, 12 and 13 are self-explanatory; specific instructions for other items are as follows:

Item Entry Item Entry

STANDARD FORM 270 (Rev. 7-97) Back

I certify that to the best of my knowledge and belief the data on the reverse are correct and that all outlays were made in accordance with the grant conditions or other agreement and that payment is due and has not been previously requested.

Public reporting burden for this collection of information is estimated to average 60 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork

Reduction Project (0348-0004), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT

AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.

Indicate whether request is prepared on cash or accrued expenditure basis. All requests for advances shall be prepared on a cash basis.

Enter the Federal grant number, or other identifying number assigned by the Federal sponsoring agency. If the advance or reimbursement is for more than one grant or other agreement, insert N/A; then, show the aggregate amounts. On a separate sheet, list each grant or agreement number and the Federal share of outlays made against the grant or agreement.

Enter the employer identification number assigned by the

U.S. Internal Revenue Service, or the FICE (institution) code if requested by the Federal agency.

This space is reserved for an account number or other identifying number that may be assigned by the recipient.

Enter the month, day, and year for the beginning and ending of the period covered in this request. If the request is for an advance or for both an advance and reimbursement, show the period that the advance will cover. If the request is for reimbursement, show the period for which the reimbursement is requested.

The Federal sponsoring agencies have the option of requiring recipients to complete items 11 or 12, but not both. Item 12 should be used when only a minimum amount of information is needed to make an advance and outlay information contained in item 11 can be obtained in a timely manner from other reports.

The purpose of the vertical columns (a), (b), and (c) is to provide space for separate cost breakdowns when a project has been planned and budgeted by program, function, or activity. If additional columns are needed, use as many additional forms as needed and indicate page number in space provided in upper right; however, the summary totals of all programs, functions, or activities should be shown in the "total" column on the first page.

Enter in "as of date," the month, day, and year of the ending of the accounting period to which this amount applies. Enter program outlays to date (net of refunds, rebates, and discounts), in the appropriate columns. For requests prepared on a cash basis, outlays are the sum of actual cash disbursements for goods and services, the amount of indirect expenses charged, the value of in-kind contributions applied, and the amount of cash advances and payments made to subcontractors and subrecipients. For requests prepared on an accrued expenditure basis, outlays are the sum of the actual cash disbursements, the amount of indirect expenses incurred, and the net increase (or decrease) in the amounts owed by the recipient for goods and other property received and for services performed by employees, contracts, subgrantees and other payees.

Enter the cumulative cash income received to date, if requests are prepared on a cash basis. For requests prepared on an accrued expenditure basis, enter the cumulative income earned to date. Under either basis, enter only the amount applicable to program income that was required to be used for the project or program by the terms of the grant or other agreement.

Only when making requests for advance payments, enter the total estimated amount of cash outlays that will be made during the period covered by the advance.

Complete the certification before submitting this request.

Note:

11a

11b

11d