Form SFN52681 "Esg/Ndhg Request for Funds" - North Dakota

What Is Form SFN52681?

This is a legal form that was released by the North Dakota Department of Commerce - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2018;
  • The latest edition provided by the North Dakota Department of Commerce;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SFN52681 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Commerce.

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Download Form SFN52681 "Esg/Ndhg Request for Funds" - North Dakota

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ESG/NDHG REQUEST FOR FUNDS
DIVISION OF COMMUNITY SERVICES
SFN 52681 (06/18)
Amount Requested
Grantee
Request Number
0.00
SO -
0.00
ES -
Phone Number Is this a Final Reimbursement?
Prepared By
0.00
HP -
Yes
No
0.00
RR -
0.00
HMIS -
Bank Name (Payee)
Bank Account Number
0.00
A - Admin
0.00
T - Total
Bank Address
Instrument Number
Date
City
ZIP Code
Phone Number Grant Begin Date
Grant End Date
FUND STATUS REPORT
A
B
1. Grant Amount
2. Funds Received to Date
3. Funds Requested, But Not Yet Received
4. Amount of this Request
5. Total Funds Request To Date (add lines 2, 3, 4)
0.00
6. Funds Available For Request (lines 1 less line 5)
0.00
7. Amount Requested: (
Enter below the use of the requested ESG/NDHG project funds as identified on your financial award)
SO - Street Outreach
HP – Homeless Prevention
HMIS
ES – Emergency Shelter
HP – Relocation & Stabilization Serv.
Admin (NDHG only)
ES – Operations
HP – Rental Assistance
ES – Essential Services
RR – Rapid Rehousing
ES – Renovation
RR – Relocation & Stabilization Serv.
RR – Rental Assistance
Total (must = line 4 above)
0.00
APPROVAL BY
CERTIFICATION
DIVISION OF COMMUNITY SERVICES
DCS Authorized Signature
Date
To the best of my knowledge, the data on this form are
correct and all disbursements were made in accordance
with grant conditions.
Signature
THIS SECTION FOR DCS USE
Yes
No
Release of Funds
Name and Title of Authorized Official
Special Conditions Released
Loan Approved
Date Signed
Authorized Signature
ESG/NDHG REQUEST FOR FUNDS
DIVISION OF COMMUNITY SERVICES
SFN 52681 (06/18)
Amount Requested
Grantee
Request Number
0.00
SO -
0.00
ES -
Phone Number Is this a Final Reimbursement?
Prepared By
0.00
HP -
Yes
No
0.00
RR -
0.00
HMIS -
Bank Name (Payee)
Bank Account Number
0.00
A - Admin
0.00
T - Total
Bank Address
Instrument Number
Date
City
ZIP Code
Phone Number Grant Begin Date
Grant End Date
FUND STATUS REPORT
A
B
1. Grant Amount
2. Funds Received to Date
3. Funds Requested, But Not Yet Received
4. Amount of this Request
5. Total Funds Request To Date (add lines 2, 3, 4)
0.00
6. Funds Available For Request (lines 1 less line 5)
0.00
7. Amount Requested: (
Enter below the use of the requested ESG/NDHG project funds as identified on your financial award)
SO - Street Outreach
HP – Homeless Prevention
HMIS
ES – Emergency Shelter
HP – Relocation & Stabilization Serv.
Admin (NDHG only)
ES – Operations
HP – Rental Assistance
ES – Essential Services
RR – Rapid Rehousing
ES – Renovation
RR – Relocation & Stabilization Serv.
RR – Rental Assistance
Total (must = line 4 above)
0.00
APPROVAL BY
CERTIFICATION
DIVISION OF COMMUNITY SERVICES
DCS Authorized Signature
Date
To the best of my knowledge, the data on this form are
correct and all disbursements were made in accordance
with grant conditions.
Signature
THIS SECTION FOR DCS USE
Yes
No
Release of Funds
Name and Title of Authorized Official
Special Conditions Released
Loan Approved
Date Signed
Authorized Signature
INSTRUCTIONS FOR COMPLETING "REQUEST FOR FUNDS"
Please do not write in any shaded areas.
GRANTEE - Same as "RECIPIENT" as shown on Financial Award.
REQUEST NUMBER - Begins with number one (1) and follows in numerical sequence for each
request submitted to DCS.
AMOUNT REQUESTED – DO NOT ENTER - this is auto filled from #7 below.
PREPARED BY - Name and telephone number of the individual preparing this request.
BANK NAME AND ADDRESS (PAYEE) - Name and address of the bank that will receive the funds
as a direct deposit. (Should be exactly as shown on Depositary Card).
INSTRUMENT NUMBER - Include the Instrument Number as assigned by DCS on the Financial
Award.
DATE - Date Request for Funds is prepared.
GRANT PERIOD - Include the grant period as specified on the Financial Award or as stated in
subsequent approved amendments.
FUND STATUS REPORT
1. Include the total grant amount as authorized on the Financial Award or any subsequent approved
amendments to the grant.
2. Include cumulative funds received to date.
3. Funds previously requested from DCS, but have not been received by grantee. (In transit).
4. Amount of this request. Must be the same as Total stated above.
5. Add Lines 2, 3 and 4, for total funds requested to date.
6. Line 1 less Line 5 for remaining funds to be drawn.
7. Identify each component as identified in your financial award for which the funds were used and
the amount to be allocated.
CERTIFICATION:
Must be signed by one of the authorized individuals shown on the
ACH Authorization Direct Deposit form (SFN 52477).
MAIL COMPLETED FORM TO:
Division of Community Services
1600 East Century Avenue, Suite 2
PO Box 2057
Bismarck, ND 58502-2057
Telephone (701) 328-5300
Fax (701) 328-5320
OR
dfaber@nd.gov
EMAIL FORM TO BOTH OF FOLLOWING ADDRESSES:
and
mhalone@nd.gov
Please include breakdown spreadsheet, your agency form explaining the payment, eviction notice
and/or lease (if applicable) and cancelled checks.
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