Laserfiche WebLink
�t OF 9 C <br />H <br />P�TEXAS. <br />REQUEST FOR PAYMENT FORM A203 <br />Grant Recipient: <br />Contract No.: <br />Request No: Region: <br />Note: All shaded field headers are interactive buttons that contain helpful information to complete this form. <br />Contract Period: From: <br />To: <br />Period Covered From: <br />by this Report: <br />To: <br />Activity Number <br />A <br />Budget <br />B <br />This Request <br />C <br />Total Drawn <br />D <br />Balance <br />(B -C -D) <br />%of Activity <br />Budget Drawn <br />Total Grant Funds: <br />Matching Funds: <br />Note: Submit supporting documentation for all costs in Column C, including costs paid through matching funds. <br />Total Grant Funds Requested To Date: Total Match Funds Expended To Date: percent match <br />funds to grant <br />0 funds expended <br />REMARKS: (if construction funds are drawn and $0 match is reported, provide explanation) <br />ALL EXPENDITURES RELATED TO THIS CONTRACT MUST BE CONSISTENT WITH THE UNIFORM GRANT AND CONTRACT <br />MANAGEMENT ACT, CHAPTER 783 OF THE TEXAS GOVERNMENT CODE, OFFICE OF MANAGEMENT AND BUDGET CIRCULAR 102, <br />AND CODE OF FEDERAL REGULATIONS TITLE 24 PART 85. <br />CERTIFICATION: By my signature below, I certify to the best of my knowledge and belief that: <br />• The data above is correct, payment is due, and the reported costs have not been previously drawn; and <br />• All activities requested for reimbursement or reported as matching funds are consistent with the TxCDBG contract, <br />Exhibit erformance Statement, and all disbursements were made in accordance with the terms of the contract. <br />N e Aut.e Certifying Official Title Signature ofAuthorized Certifying Official Date <br />Name of 2nd Authorized Certifying Official Title g a ure ofAuthorized Certifying Official Date <br />Form must be signed and dated by authorized signatories. <br />Revised form required as of October 21, 2013. <br />k&4 1,11 I , <br />TDA Program File Use Only <br />Specialist Approval: Date: <br />