"Request Form for Advance or Reimbursement"

Request Form for Advance or Reimbursement is a 3-page legal document that was released by the U.S. Department of Agriculture and used nation-wide.

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Download "Request Form for Advance or Reimbursement"

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OMB Number: 4040-0012
Expiration Date: 01/31/2019
a. "X" one or both boxes
2. BASIS OF REQUEST
ADVANCE
CASH
1.
REIMBURSEMENT
TYPE OF
REQUEST FOR ADVANCE
ACCRUAL
PAYMENT
b. "X" the applicable box
OR REIMBURSEMENT
REQUESTED
FINAL
PARTIAL
4. FEDERAL GRANT OR OTHER IDENTIFYING NUMBER
3. FEDERAL SPONSORING AGENCY AND ORGANIZATIONAL
ASSIGNED BY FEDERAL AGENCY
ELEMENT TO WHICH THIS REPORT IS SUBMITTED
5. PARTIAL PAYMENT REQUEST
6. EMPLOYER IDENTIFICATION
7. FINANCIAL ASSISTANCE
NUMBER FOR THIS REQUEST
NUMBER
IDENTIFICATION NUMBER
8.
PERIOD COVERED BY THIS REQUEST
From:
To:
9. RECIPIENT ORGANIZATION
Name:
Street1:
Street2:
City:
County:
State:
Province:
Country:
ZIP / Postal Code:
10. PAYEE (Where check is to be sent if different than item 9)
Name:
Street1:
Street2:
City:
County:
State:
Province:
Country:
ZIP / Postal Code:
OMB Number: 4040-0012
Expiration Date: 01/31/2019
a. "X" one or both boxes
2. BASIS OF REQUEST
ADVANCE
CASH
1.
REIMBURSEMENT
TYPE OF
REQUEST FOR ADVANCE
ACCRUAL
PAYMENT
b. "X" the applicable box
OR REIMBURSEMENT
REQUESTED
FINAL
PARTIAL
4. FEDERAL GRANT OR OTHER IDENTIFYING NUMBER
3. FEDERAL SPONSORING AGENCY AND ORGANIZATIONAL
ASSIGNED BY FEDERAL AGENCY
ELEMENT TO WHICH THIS REPORT IS SUBMITTED
5. PARTIAL PAYMENT REQUEST
6. EMPLOYER IDENTIFICATION
7. FINANCIAL ASSISTANCE
NUMBER FOR THIS REQUEST
NUMBER
IDENTIFICATION NUMBER
8.
PERIOD COVERED BY THIS REQUEST
From:
To:
9. RECIPIENT ORGANIZATION
Name:
Street1:
Street2:
City:
County:
State:
Province:
Country:
ZIP / Postal Code:
10. PAYEE (Where check is to be sent if different than item 9)
Name:
Street1:
Street2:
City:
County:
State:
Province:
Country:
ZIP / Postal Code:
11.
COMPUTATION OF AMOUNT OF REIMBURSEMENTS/ADVANCES REQUESTED
PROGRAMS/FUNCTIONS/
(a)
(b)
(c)
ACTIVITIES
TOTAL
(As of date)
a. Total program
$
$
$
$
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. Advances required
1st month
by month, when
requested by Federal
2nd month
grantor agency for
use in making
prescheduled
3rd month
advances
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)
13.
CERTIFICATION
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.
SIGNATURE OR AUTHORIZED CERTIFYING OFFICIAL
DATE REQUEST SUBMITTED
TYPED OR PRINTED NAME AND TITLE
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Title:
TELEPHONE (AREA CODE, NUMBER, EXTENSION)
This space for agency use
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.
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
2 Indicate whether request is prepared on cash or accrued
as many additional forms as needed and indicate page
expenditure basis. All requests for advances shall be
number in space provided in upper right; however, the
prepared on a cash basis.
summary totals of all programs, functions, or activities
should be shown in the "total" column on the first page.
4 Enter the Federal grant number, or other identifying number
assigned by the Federal sponsoring agency. If the advance
11a Enter in "as of date," the month, day, and year of the
or reimbursement is for more than one grant or other
ending of the accounting period to which this amount
agreement, insert N/A; then, show the aggregate amounts.
applies. Enter program outlays to date (net of refunds,
On a separate sheet, list each grant or agreement number
rebates, and discounts), in the appropriate columns. For
and the Federal share of outlays made against the grant or
requests prepared on a cash basis, outlays are the sum
agreement.
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
6 Enter the employer identification number assigned by the
advances and payments made to subcontractors and
U.S. Internal Revenue Service, or the FICE (institution)
subrecipients. For requests prepared on an accrued
code if requested by the Federal agency.
expenditure basis, outlays are the sum of the actual
cash disbursements, the amount of indirect expenses
7 This space is reserved for an account number or other
incurred, and the net increase (or decrease) in the
identifying number that may be assigned by the recipient.
amounts owed by the recipient for goods and other
property received and for services performed by
8 Enter the month, day, and year for the beginning and
employees, contracts, subgrantees and other payees.
ending of the period covered in this request. If the request
is for an advance or for both an advance and
11b Enter the cumulative cash income received to date, if
reimbursement, show the period that the advance will
requests are prepared on a cash basis. For requests
cover. If the request is for reimbursement, show the period
prepared on an accrued expenditure basis, enter the
for which the reimbursement is requested.
cumulative income earned to date. Under either basis,
enter only the amount applicable to program income
Note: The Federal sponsoring agencies have the option of
that was required to be used for the project or program
requiring recipients to complete items 11 or 12, but not
by the terms of the grant or other agreement.
both. Item 12 should be used when only a minimum
amount of information is needed to make an advance
11d Only when making requests for advance payments,
and outlay information contained in item 11 can be
enter the total estimated amount of cash outlays that
obtained in a timely manner from other reports.
will be made during the period covered by the advance.
11 The purpose of the vertical columns (a), (b), and (c) is to
13 Complete the certification before submitting this request.
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
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