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<br /> 13- CERTIFICATION
<br /> SIGNATURE OR AUTHORIZED CERTIFYING OFFICIAL DATE REQUEST
<br /> I certify that to the best of my knowledge
<br /> SUBMITTED
<br /> and belief the data on the reverse are
<br /> correct and that all outlays were made in
<br /> accordance with the grant conditions or TYPED OR PRINTED NAME AND TITLE TELEPHONE(AREA
<br /> other agreement and that payment is due CODE,NUMBER,
<br /> and has not been previously requested. EXTENSION)
<br /> This space for agency use
<br /> Public reporting burden for this collection of information is estimated to average 80 minutes per
<br /> response,including time for reviewing instructions,searching existing data sources,gathering and
<br /> maintaining the data needed, and completing and reviewing the collection of information. Send
<br /> comments regarding the burden estimate or any other aspect of this collection of information,
<br /> including suggestions for reducing this burden, to the Office of Management and Budget,
<br /> Paperwork Reduction Project(0348-0004),Washington,DC 20503.
<br /> PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT
<br /> AND BUDGET.SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
<br /> INSTRUCTIONS
<br /> Please type or print legibly. Items 1,3,5,9, 10, 11 e, '11f, 11g, 11 i, 12 and 13 are self-explanatory; specific
<br /> instructions for other items are as follows:
<br /> Item Entry Item Entry
<br /> 2 Indicate whether request is prepared on cash or accrued as many additional forms as needed and indicate page
<br /> expenditure basis. All requests for advances shall be number in space provided in upper right; however, the
<br /> prepared on a cash basis. summary totals of all programs, functions, or activities
<br /> should be shown in the"total"column on the first page.
<br /> 4 Enter the Federal grant number,or other identifying number
<br /> assigned by the Federal sponsoring agency. If the advance
<br /> or reimbursement is for more than one grant or other 11 a Enter in "as of date," the month, day, and year of the
<br /> agreement, insert N/A; then, show the aggregate amounts. ending of the accounting period to which this amount
<br /> On a separate sheet, list each grant or agreement number applies. Enter program outlays to date (net of refunds,
<br /> and the Federal share of outlays made against the grant or rebates, and discounts), in the appropriate columns. For
<br /> agreement. requests prepared on a cash basis, outlays are the sum of
<br /> actual cash disbursements for goods and services, the
<br /> 6 Enter the employer identification number assigned by the amount of indirect expenses charged, the value of in-kind
<br /> U.S. Internal Revenue Service, or the FICE (institution) contributions applied, and the amount of cash advances
<br /> code if requested by the Federal agency. and payments made to subcontractors and subrecipients.
<br /> For requests prepared on an accrued expenditure basis,
<br /> 7 This space is reserved for an account number or other outlays are the sum of the actual cash disbursements,the
<br /> identifying number that may be assigned by the recipient. amount of indirect expenses incurred,and the net increase
<br /> (or decrease) in the amounts owed by the recipient for
<br /> 8 Enter the month, day, and year for the beginning and goods and other property received and for services
<br /> ending of the period covered in this request. If the request oer by employees, contracts, subgrantees and
<br /> is for an advance or for both an advance and other r payees.
<br /> reimbursement, show the period that the advance will
<br /> cover. If the request is for reimbursement, show the period 11 b Enter the cumulative cash income received to date, if
<br /> for which the reimbursement is requested. requests are prepared on a cash basis. For requests
<br /> prepared on an accrued expenditure basis, enter the
<br /> Note: The Federal sponsoring agencies have the option of cumulative income earned to date. Under either basis,
<br /> requiring recipients to complete items 11 or 12, but not enter only the amount applicable to program income that
<br /> both. Item 12 should be used when only a minimum was required to be used for the project or program by the
<br /> amount of information is needed to make an advance and terms of the grant or other agreement.
<br /> outlay information contained in item 11 can be obtained in
<br /> a timely manner from other reports. lid Only when making requests for advance payments, enter
<br /> the total estimated amount of cash outlays that will be
<br /> 11 The purpose of the vertical columns (a), (b), and (c) is to made during the period covered by the advance.
<br /> provide space for separate cost breakdowns when a
<br /> project has been planned and budgeted by program, 13 Complete the certification before submitting this request.
<br /> function,or activity.If additional columns are needed,use
<br /> STANDARD FORM 270(Rev.7-571 Back
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