Exhibit B "Request for Funds Form - Governor's Emergency Education Relief Funds" - Louisiana

What Is Exhibit B?

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

Form Details:

  • Released on June 24, 2020;
  • The latest edition provided by the Louisiana Division of Administration;
  • 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 printable version of Exhibit B by clicking the link below or browse more documents and templates provided by the Louisiana Division of Administration.

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Download Exhibit B "Request for Funds Form - Governor's Emergency Education Relief Funds" - Louisiana

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Exhibit B
Request for Funds Form
Governor's Emergency Education Relief Funds (CFDA 84:425C)
GEERF_DOA@la.gov
Upon completion of form, attach all required supporting documentation and submit packet to 
Subrecipient  Name:
Date of Request:
Applicable State Fiscal Month/Year:
DUNS Number:
Amount of Request:
Purpose / Use of Funds: 
By my signature below, I certify that (1) this request for funds only includes costs for allowed uses, (2) all required compliance requirements for this
program have been met, (3) all required supporting documentation to substantiate the request has been provided or will be provided in accordance
with grant handbook requirements, (4) if funds will be remitted to subrecipient(s), they will be done so within 2 business days of receipt of funds from
DOA, and (5) the required reporting to the DOA, if applicable, will be submitted on the 5th day of the following month.
(Printed Name of Individual Submitting Request / Title)
(Digital Signature of Individual Submitting Request)
(Email Address)
(Telephone Number)
For OFSS Use Only
Date of Receipt:
Original Budget Authority:
Allowable Payment:
Expended Budget Amount:
(Including this Request)
Internal RFF Number:
Date of Draw:
Remaining Budget Authority:
$0.00
(After this Request)
Date of Payment:
Payment Transaction #:
Notes:
 6/24/2020
Exhibit B
Request for Funds Form
Governor's Emergency Education Relief Funds (CFDA 84:425C)
GEERF_DOA@la.gov
Upon completion of form, attach all required supporting documentation and submit packet to 
Subrecipient  Name:
Date of Request:
Applicable State Fiscal Month/Year:
DUNS Number:
Amount of Request:
Purpose / Use of Funds: 
By my signature below, I certify that (1) this request for funds only includes costs for allowed uses, (2) all required compliance requirements for this
program have been met, (3) all required supporting documentation to substantiate the request has been provided or will be provided in accordance
with grant handbook requirements, (4) if funds will be remitted to subrecipient(s), they will be done so within 2 business days of receipt of funds from
DOA, and (5) the required reporting to the DOA, if applicable, will be submitted on the 5th day of the following month.
(Printed Name of Individual Submitting Request / Title)
(Digital Signature of Individual Submitting Request)
(Email Address)
(Telephone Number)
For OFSS Use Only
Date of Receipt:
Original Budget Authority:
Allowable Payment:
Expended Budget Amount:
(Including this Request)
Internal RFF Number:
Date of Draw:
Remaining Budget Authority:
$0.00
(After this Request)
Date of Payment:
Payment Transaction #:
Notes:
 6/24/2020
Exhibit B
Name of Agency Requesting Funds
Subrecipient Name
Date Request is Made
Date of Request
Appropriate State Fiscal Month and Year of Actual Expenditure
Applicable State Fiscal Month/Year
Agency DUNS #
DUNS #
Amount of Actual Request
Amount of Request
Include description of how expenditure meets the required use of funds 
Purpose for Use of Funds
and explanation as to why amount of request may not agree to attached 
invoices and/or supporting documentation
Printed Name and Title of Individual Submitting Request
Printed Name of Individual Submitting Request/Title
Digital Signature of Individual Submitting Request
Digital Signature of Individual Submitting Request
Email Address of Individual Submitting Request
Email Address
Telephone Number of Individual Submitting Request
Telephone Number
Internal Use Section:
Recorded by Financial Reporting as Date Received Email and Supporting 
Date of Receipt:
Documentation
Allowable Payment:
Amount Determined to be Allowable by Financial Reporting
*Internal RFF Number:
Internally Assigned Request for Funds Number by Financial Reporting
Recorded by  Cash Disbursements as the Date Received Packet via Email 
Date Received by Cash Disbursements
from Financial Reporting
Date of Draw by Financial Reporting
Date of Draw:
Date of Payment:
Date of Payment Recorded by Cash Disbursements
System Transaction # Recorded by Cash Disbursement
Payment Transaction #:
Amount of Award to Pass‐Through Entity
Original Budget Authority:
Expended Budget Amount:
Amount of Award Expended and Passed Through to Pass‐Through Entity
Budget Authority Remaining after all Expended Amounts (Including 
Remaining Budget Authority:
Current Allowed Payment Per this RFF)
* The Internal RFF Number must be entered on the payment document in the system to match the payment to the request,
providing an audit trail.
Instructions
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