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ATTACHMENT C-2: NCPRO Coronavirus grant <br /> Monthly Reimbursement Request <br />Attachment C-1 must accompany this form to receive reimbursement from NCPRO. <br />RECIPIENT COMPLETION INFORMATION: Email completed form to: «UploadLink» <br /> <br />PART A: Summary of Funding Received and Spent <br /> <br /> <br /> <br /> <br />NAME OF RECIPIENT <br />ORGANIZATION: <br /> <br /> <br /> <br />Contract <br />Agreement <br />Number <br /> <br /> <br /> <br />Total Funding <br />Authorized by HB <br />1043: <br /> <br /> <br /> <br /> <br /> <br /> <br />Advance <br /> <br /> <br /> <br />July Reimbursement <br />Request <br />(Details in Part B) <br /> <br /> <br />August <br />Reimbursement <br />Request <br />(Details in Part B) <br /> <br /> <br />September <br />Reimbursement <br />Request <br />(Details in Part B) <br /> <br /> <br />October <br />Reimbursement <br />Request <br />(Details in Part B) <br /> <br /> <br />November <br />Reimbursement <br />Request <br />(Details in Part B) <br /> <br /> <br />December <br />Reimbursement <br />Request <br />(Details in Part B) <br />January <br />Reimbursement <br />Request for <br />December <br />Expenses <br />(Details in Part B) <br /> <br /> <br /> <br /> <br />Total Received to <br />Date <br /> <br /> <br /> <br /> <br />Point of Contact <br />Name <br /> <br /> <br /> <br /> <br /> <br /> <br />Point of Contact Title: <br /> <br /> <br /> <br /> <br />Point of <br />Contact Email <br /> <br /> <br /> <br /> <br />Point of Contact <br />Phone Number <br /> <br />«RecipientName» <br />«Agreement» <br /> <br />«AmountPerSL» <br /> <br />«HalfAmount» <br /> <br />«HalfAmount» <br /> <br />«POCName» <br /> <br />«POCTitle» <br /> <br />«DirectEmail»i <br /> <br />«POCPhone» <br /> <br /> <br />PLEASE REMEMBER INDIRECT COST ALLOCATION AND PERCENTAGE OF ADMINISTRATION COST ARE UNALLOWABLE <br />PART B: Detailed Expense (In lieu of completing Part B manually, detailed information can be exported from your systems in Ex cel or .CSV format, however, at min imum, the requested fields must be provided) <br /> <br /> <br />Recipient Name <br />or <br />Subrecipient Name <br /> <br /> <br />Date of Invoice, <br />payroll, or <br />service, <br /> <br /> <br />Employee Name <br />or <br />Vendor Name or <br />Contractor <br /> <br /> <br />Employee ID <br />Number <br />or <br />Invoice Number <br /> <br /> <br />Employee Title <br />or <br />Description of Item <br />Purchased <br /> <br />Required Monthly <br />Hours Worked <br />or <br />Total Invoice <br />Amount <br />Actual Employee <br />Hours Dedicated to <br />COVID <br />or <br />Invoice Quantity <br />or <br /># of Patients Served <br /> <br />Employee Expenses <br />(Payroll and benefits <br />cost for employee <br />that are dedicated to <br />COVID-19 ) <br /> <br /> <br /> <br />Contracted Labor <br />Expenses <br /> <br />Other Service <br />Expenses (e.g. <br />utilities, telephone, <br />data, lease related <br />expenses) <br /> <br /> <br />Subcontract <br />Expenses (e.g. <br />construction, <br />maintenance) <br /> <br /> <br />Goods Expenses <br />(e.g. supplies, <br />PPE) <br /> <br /> <br /> <br />Equipment <br />Expenses <br /> <br />Other Expenses (e.g. related <br />charges not assigned in <br />columns H-M and described <br />by recipient, such as, <br />patient services) <br /> <br /> <br /> <br />TOTAL <br />Expenditures <br /> <br />Is the Vendor a <br />Historically <br />Underutilized <br />Business (HUB)? <br />(YES or No) <br />Ex. «RecipientName» vendor 4/1/2020 joe vendor INV 123 reagents $ 8,975.00 10 $ 8,975.00 $ 8,975.00 NO <br />Ex. «RecipientName» <br />employee <br />4/5/2020 jane doe EMP ID a345 researcher 160.00 120 $ 6,000.00 $ 6,000.00 NA <br />Ex.«RecipientName» <br />contractor <br />4/28/2020 pet store INV 75892 cages $ 3,216.00 5 $ 3,216.00 $ 3,216.00 yes <br />Ex. «RecipientName» <br />Subrecipient <br /> $ - <br /> $ - <br /> $ - <br /> $ - <br />DocuSign Envelope ID: A0668E2C-EC33-465B-A5EE-E1302408AA65