|
<br />13.
<br />
<br />CERTIFICATION
<br />SIGNATURE OR AlITHORIZED CERTIFYING OFFICIAL
<br />
<br />DAne REQUEST
<br />SUBMITTED
<br />
<br />I certify that to the best of my
<br />~owIedge and belief the data on the
<br />reverse are correct and that all outlays
<br />were made In accordance with the
<br />grant conditions or other agreement
<br />and that payment Is due and has not
<br />been prevtously requested.
<br />
<br />This space for agency use
<br />
<br />TYPED OR PRINTED NAME AND TITLE
<br />
<br />TELEPHONE (AREA
<br />CODE, NUMBER,
<br />EXTENSION)
<br />
<br />.~.. -~-_.. --.- -..-. . .-..--..-....----...-.. - -....-..- -. --.-.---...- -.._.
<br />Public reporting burden for this collection of Information Is estimated to average 60 minutes per
<br />response, Including time for reviewing Instructions, searching exlsllng data sources, gathering and
<br />maintaining the data needed, and completing and reviewing the collection of Infonnation. Send
<br />comments regarding the burden estimate or any other aspect of this collection of Infonnatlon,
<br />Including suggestions for reducing this burden, to the Offlce of Management and Budget, Paperwork
<br />Reduction Project (0348-0004), Washington, DC 20503.
<br />
<br />PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT
<br />AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
<br />
<br />INSTRUCTIONS
<br />Please type or print legibly. Items 1, 3,.5, 9, 10, 11e, 11f, 11g, 11 i, 12 and 13 are self-explanatory; specific
<br />instructions for other items are as follows:
<br />Item Entry Item Entry
<br />
<br />2 Indicate whether request is prepared on cash or accrued
<br />expenditure basis. All requests for advances shall be
<br />prepared on a cash basis.
<br />
<br />activity. If additional columns are needed, use as many
<br />additional forms as needed and indicate page number in
<br />space provided in upper right; however, the summary
<br />totals of all programs, functions, or activities should be
<br />shown in the "total" column on the first page.
<br />
<br />4 Enter the Federal grant number, or other identifying
<br />number assigned by the Federal sponsoring agency. If
<br />the advance or reimbursement is for more than one grant
<br />or other agreement, insert N/A; then, show the aggregate
<br />amounts. On a separate sheet, list each grant or
<br />agreement number and the Federal share of outlays
<br />made against the grant or agreement.
<br />
<br />11a
<br />
<br />Enter in "as of date," the month, day, and year of the
<br />ending of the accounting period to which this amount
<br />applies. Enter program outlays to date (net of refunds,
<br />rebates, and discounts), in the appropriate columns. For
<br />requests prepared on a cash basis, outlays are the sum
<br />of actual cash disbursements for goods and services,
<br />the amount of indirect expenses charged, the value of in-
<br />kind contributions applied, and the amount of cash
<br />advances and payments made to subcontractors and
<br />subrecipients. For requests prepared on an accrued
<br />expenditure basis, outlays are the sum of the actual
<br />cash disbursements, the amount of Indirect expenses
<br />incurred, and the net increase (or decrease) In the
<br />amounts owed by the recipient for goods and other
<br />property received and for services performed by
<br />employees, contracts, subgrantees and other payees.
<br />
<br />E~ter the cumulative cash Income received to date, if
<br />requests are prepared on a cash basis. For requests
<br />prepared on an accrued expenditure basis, enter the
<br />cumulative Income earned to date. Under either basis,
<br />enter only the amount applicable to program Income that
<br />was required to be used for the project or program by
<br />the terms of the grant or other agreement.
<br />
<br />6 Enter the employer identification number assigned by the
<br />U.S. Internal Revenue Service, or the FleE (institution)
<br />code if requested by the Federal agency.
<br />
<br />7 This space is reserved for an account number or other
<br />identifying number that may be assigned by the recipient.
<br />
<br />8 Enter the month, day, and year for the beginning and
<br />ending of the period covered In this request. If the request
<br />is for an advance or for both an advance and
<br />reimbursement, show the period that the advance will
<br />cover. If the request is for reimbursement, show the
<br />period for which the reimbursement is requested.
<br />
<br />11b
<br />
<br />Note: The Federal sponsoring agencies have the option of
<br />requiring recipients to complete items 11 or 12, but not
<br />both. Item 12 should be used when only a minimum
<br />amount of information is needed to make an advance and
<br />outlay information contained in item 11 can be obtained In
<br />a timely manner from other reports.
<br />
<br />11d
<br />
<br />Only when makIng requests for advance payments,
<br />enter the total estimated amount of cash outlays that will
<br />be made during the period covered by the advance.
<br />
<br />11 The purpose of the vertical columns (a), (b), and (c) Is to
<br />provide space for separate cost breakdowns when a
<br />project has been. planned and budgeted by program,
<br />function, or
<br />
<br />13 Complete the certification before submitting this request.
<br />STANDARD FORM 270 (Rev. 7.97) Beck
<br />
|