Form MSCD/ITAB-194 "Supplement to Carb's Advance Payment Request Form: AB 617 Community Air Protection (CAP) Incentives Grant Disbursement Request" - California

What Is Form MSCD/ITAB-194?

This is a legal form that was released by the California Air Resources Board - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2021;
  • The latest edition provided by the California Air Resources Board;
  • 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 MSCD/ITAB-194 by clicking the link below or browse more documents and templates provided by the California Air Resources Board.

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Download Form MSCD/ITAB-194 "Supplement to Carb's Advance Payment Request Form: AB 617 Community Air Protection (CAP) Incentives Grant Disbursement Request" - California

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STATE OF CALIFORNIA
CALIFORNIA ENVIRONMENTAL PROTECTION AGENCY
CALIFORNIA AIR RESOURCES BOARD
SUPPLEMENT TO CARB’S ADVANCE PAYMENT REQUEST FORM: AB 617 COMMUNITY AIR
PROTECTION (CAP) INCENTIVES GRANT DISBURSEMENT REQUEST
MSCD/ITAB-194 (REV. 04/2021) PAGE 1 OF 2
PART A: GRANTEE INFORMATION
Grantee:
Date:
Grant Number:
Number of Request:
CAP Incentives Funding Year:
Fiscal Year:
An Air District with a population greater than or equal to four million (4,000,000):
If yes, check this box
Project Funds:
Implementation Funds:
Total Funds Requested:
Make Warrant Payable to District:
Address Number and Street:
City, State, and Zip Code:
The address provided above matches the address provided on the Air District’s Payee Data Record
204) or Government Agency Taxpayer ID Form
(Taxpayer
Form):
Form
(STD.
If no, District will be submitting a corrected STD. 204 or Taxpayer Form to CARB.
Yes
PART B: COMMUNITY AIR PROTECTION DISBURSEMENT SUBMITTALS
The air district has included all of the following items with the disbursement request:
Documentation of a public process to solicit project ideas from local residents and community
groups, and an air district summary of the results of that process.
A project list with the total cost of projects equal to or greater than the amount of funds being
requested. The air district will indicate whether each project listed satisfies evaluation criteria for
benefits to priority populations, per the CCI Funding Guidelines criteria for Clean Transportation
and Equipment (www.arb.ca.gov/cci-resources).
Completed
ASD/BFB-365, Advance Payment Request Form
PART C: ADDITIONAL DISTURSEMENT REQUIREMENTS
The air district has met all of the following additional disbursement requirements:
The air district has met all stipulations listed in the air district’s CAP Incentives Grant Agreement.
The most recent CAP Incentives Yearly Report has been submitted to CARB. Grant
disbursement approval will be subject to CARB’s determination that the Yearly Report indicates
expenditure milestones have been met, or if necessary, unexpended funds have been returned to
CARB.
An up-to-date policies and procedures manual for the District’s CAP Incentives is maintained at
the District’s office.
STATE OF CALIFORNIA
CALIFORNIA ENVIRONMENTAL PROTECTION AGENCY
CALIFORNIA AIR RESOURCES BOARD
SUPPLEMENT TO CARB’S ADVANCE PAYMENT REQUEST FORM: AB 617 COMMUNITY AIR
PROTECTION (CAP) INCENTIVES GRANT DISBURSEMENT REQUEST
MSCD/ITAB-194 (REV. 04/2021) PAGE 1 OF 2
PART A: GRANTEE INFORMATION
Grantee:
Date:
Grant Number:
Number of Request:
CAP Incentives Funding Year:
Fiscal Year:
An Air District with a population greater than or equal to four million (4,000,000):
If yes, check this box
Project Funds:
Implementation Funds:
Total Funds Requested:
Make Warrant Payable to District:
Address Number and Street:
City, State, and Zip Code:
The address provided above matches the address provided on the Air District’s Payee Data Record
204) or Government Agency Taxpayer ID Form
(Taxpayer
Form):
Form
(STD.
If no, District will be submitting a corrected STD. 204 or Taxpayer Form to CARB.
Yes
PART B: COMMUNITY AIR PROTECTION DISBURSEMENT SUBMITTALS
The air district has included all of the following items with the disbursement request:
Documentation of a public process to solicit project ideas from local residents and community
groups, and an air district summary of the results of that process.
A project list with the total cost of projects equal to or greater than the amount of funds being
requested. The air district will indicate whether each project listed satisfies evaluation criteria for
benefits to priority populations, per the CCI Funding Guidelines criteria for Clean Transportation
and Equipment (www.arb.ca.gov/cci-resources).
Completed
ASD/BFB-365, Advance Payment Request Form
PART C: ADDITIONAL DISTURSEMENT REQUIREMENTS
The air district has met all of the following additional disbursement requirements:
The air district has met all stipulations listed in the air district’s CAP Incentives Grant Agreement.
The most recent CAP Incentives Yearly Report has been submitted to CARB. Grant
disbursement approval will be subject to CARB’s determination that the Yearly Report indicates
expenditure milestones have been met, or if necessary, unexpended funds have been returned to
CARB.
An up-to-date policies and procedures manual for the District’s CAP Incentives is maintained at
the District’s office.
STATE OF CALIFORNIA
CALIFORNIA ENVIRONMENTAL PROTECTION AGENCY
CALIFORNIA AIR RESOURCES BOARD
SUPPLEMENT TO CARB’S ADVANCE PAYMENT REQUEST FORM: AB 617 COMMUNITY AIR
PROTECTION (CAP) INCENTIVES GRANT DISBURSEMENT REQUEST
MSCD/ITAB-194 (REV. 04/2021) PAGE 2 OF 2
PART D: CERTIFICATION AND SIGNATURE OF AUTHORIZED PROGRAM OFFICIAL
I certify under penalty of perjury that the information contained in this Supplement to CARB’s
Advance Payment Request Form, and all attachments, is correct and complete, and is in accordance
with the Terms and Conditions of the Grant Agreement. I agree to not provide advance payment to
any other entity. In addition, I hereby authorize CARB to make any inquiries to confirm this
information.
Signature of Authorized Program Official:
Name:
Title:
Date:
PART E: FOR STATE USE ONLY
Liaison’s Printed Name
Liaison’s Signature:
Date:
Grant Manager’s Printed Name:
Grant Manager’s Signature:
Date:
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