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13. CERTIFICATION
<br />I cerGy that to lhe best of my
<br />ImovAedge and Delief the data on the
<br />reverse ere correct and that ail ouUays
<br />were made in eccordance with the
<br />grant condttlons or other agreement
<br />and that payment Is due and has not
<br />been prevlousyrequested.
<br />agency use
<br />NUMBER,
<br />Pubiic reporting burden for thls collection o( Intormation Is estimated to average 60 minutes per
<br />response, Including tlme for reviewing Instructlons, searching edsting data sources, gatheAng and
<br />maintaining the data needed, and wmpletlng and reNewing Ne wllection of Infortnation. Send
<br />commenls regarding the burden estlmate or any other aspect of lhis wllectlon of Infortnation,
<br />including suggestions for reducing thfs burden, to the Office of Management end Budget, Papervrork
<br />Reductlon ProJect (0348-0004), Washington, DC 20503.
<br />PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT
<br />AND BUDGET. SEND 1T TO THE AODRESS PROVIDED BY THE SPONSORING AGENCY.
<br />INSTRUCTIONS
<br />Please type or print legibly. Items 1, 3,5, 9, 10, 11e, 11f, 11g, 11i, 12 and 13 are self-explanatory; specific
<br />instructions for other items are as followr. 2 Indicate whether request is prepared on cash or accrued
<br />expenditure basis. AII requests for advances shall be
<br />prepared on a cash basis.
<br />Enter the Federal grant number, or other identifying
<br />number assigned by the Federai sponsoring agency. If
<br />the advance or reimbursement is for more than one grent
<br />or other agreement, Insert N/A; then, show the aggregate
<br />amounts. On a separete sheet, list each grant or
<br />agreement number and the Federal share of outlays
<br />made against the grant or agreement.
<br />6 Enter the employer identifcation number assigned by the
<br />U.S. Internal Revenue Service, or the FICE (institution)
<br />code if requested by the Federel agency.
<br />7 This space is reserved for an account number or other
<br />identifying number that may be assigned by the recipient.
<br />8 Enter the month, day, and year for the Deginning and
<br />ending of the period covered In this request. If the request
<br />Is for an advance or tor both an advance and
<br />reimbursement, show the period that the advance will
<br />cover. If the request Is for reimbursement, show the lly
<br />period for which the reimbursement Is requested.
<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 contalned In Item 11 can be obtafned In
<br />a timely manner from other reports.
<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 />tunction, or
<br />activity. If additional columns are needed, use as many
<br />additionai 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 />Enter in "as of date," the month, day, and year of the
<br />ending of the accounting pertod to which this amount
<br />appiies. Enter progrem outlays to date (net of refunds,
<br />rebates, and discounts), in the appropriate coiumns. 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 subcontrectors end
<br />subrecipients. For requests prepared on an accrued
<br />expenditure basis, outlays are the sum of the actual
<br />cash disbursements, the amount o1 Indirect expenses
<br />incurred, and the net increase (or decrease) in the
<br />amounts owed by the recipient tor goods and other
<br />property recefved and for services performed by
<br />employees, contracts, subgrantees and other payees.
<br />11a
<br />Enter the cumulative cash income received to date, If
<br />requests are prepared on a cash basis. For requests
<br />prepared on an accrued expenditure basls, enter the
<br />cumulative Income earned to date. Under either basis,
<br />enter only the amount applicable to pragram income that
<br />was required to be used for the projed or program by
<br />the terms of the grant or other agreement.
<br />11d Only when makfng requests for advance payments,
<br />enter the total estfmated amount of cash outlays that wili
<br />be made during the period covered by the advanca.
<br />13 Compietetha certification before submitting this request.
<br />STANOMD FORM 270 (Iw.7•07) Bxk
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