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G.R.E.A.T.Program <br />OMBMPROVALNO. <br />PME . OF <br />~ <br />0348-0004 <br />PAcES <br />REQUEST FOR ADVANCE <br />,x•~a,ab,,,,, <br />2eAM oF nE«,ESr <br />OR REIMBURSEMENT <br />1• <br />❑ADVANCE ❑ REIMBURSE- <br />ttaeov <br />MEM <br />❑CASH <br />nAveeern <br />e.xen..ca~r~a.m. <br />. (Sae InsWctlons on bad) <br />REWESfED <br />El FINAL ❑ PARTIAL <br />❑ ACCRUAL <br />3. FEDERAL SPONSORING AGENCY AND ORGAM7ATONAI EIEMENT TO <br />1. FEDERAL GRA61T OR OTHER <br />5. PMML PAYMQJf REpJEST <br />WHICHTHISREPORTISSUBMffTEO <br />pENfIFltN('ryUM8ERA55I0NED <br />NUMBERFORiM5RE0UESf <br />-BYFEDERALAOENGY... . <br />. <br />6. EMPLOYQi IDETIfIFlCATION <br />7. RKIPIEM'S ACCIX1Nf NUMBER <br />S. PERIOD COVERED BY THIS REQUEST <br />NUMBER <br />OR IDEMIFYING NUMBER <br />FROM (ma+N, Gy, year) TO (monM, Lq, ye0 <br />9. REGPIEM ORGRNVATON <br />70. PAYEE (lMMchecN is ro be sent ll mRerenf fhan ttem 9) <br />Name: <br />Nama: <br />Num6er <br />Num6er . ' <br />and Streeh <br />and SYreet: - <br />Cify, Stata <br />dty, State <br />and ZIP Code: <br />and ZIP Code: <br />11, COMPUTATION OF AMOUNT OF REIMBURSE M ENTS/ADVANCES REQUESTED <br />(e) <br />(b) <br /> <br />PROGRAMS/FUNCTIONSIACTIVITIES ► <br />TOTAL <br />a. Total program (a+wdele) <br />outla to date <br />$ <br />$ <br />$ <br />$ <br />b. Less: CumuWtNe r ram Income <br />c. Net program oWays (Une a minus <br />Bne 6 <br />d. EsUmated net cash outlays tor advance <br />rbd <br />e. Total Sum olOnes c 8 <br />f. Nan-Federai sharc of amount on Ilne e <br />. Federai share of amount on Ilne e <br />. <br />h. Fede21 payments prevlousty veshd <br />1. Federal share now requested (IJne g <br />minuslns h <br />1. Advances MOW ~ <br />uesled <br />when re <br />b <br />tstmonth <br />q <br />mon <br />, <br />Dy Federal 9ranta <br />ki <br />I <br />Znd month <br />n ma <br />ng <br />egenq la use <br />. <br />presdieduled edvances <br />3rd monlh <br />12.- ALTERNATE COMPUTATION FOR Aovqrvces orvLT <br />a Estimated Fede21 eash outlays that wili be made during perlod covered by the advarke <br />b. Lsss: Estlmated batarKe ot Federal wsh on hand as ol beginning of advexe perbd <br />PreseriDed by OMB Clrctdam A-702 and A-170 <br />