Form 271 - Outlay Report And Request For Reimbursement For Construction Programs

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PAGE
OF
OUTLAY REPORT AND REQUEST FOR REIMBURSEMENT
OMB APPROVAL NO. 0348-0002
FOR CONSTRUCTION PROGRAMS
PAGES
1. TYPE OF REQUEST
2. BASIS OF REQUEST
(See instructions on back)
FINAL
PARTIAL
CASH
ACCRUAL
4. FEDERAL GRANT OR OTHER IDENTIFYING NUMBER
5. PARTIAL PAYMENT REQUEST NO.
3. FEDERAL SPONSORING AGENCY AND ORGANIZATIONAL
ASSIGNED BY FEDERAL AGENCY
ELEMENT TO WHICH THIS REPORT IS SUBMITTED
PERIOD COVERED BY THIS REQUEST
6. EMPLOYER IDENTIFICATION
7. RECIPIENT'S ACCOUNT NUMBER
NUMBER
OR IDENTIFYING NUMBER
FROM (Month, day, year)
TO (Month, day, year)
9. RECIPIENT ORGANIZATION
10. PAYEE (Where check is to be sent if different than item 9)
Name:
Name:
No. and Street:
No. and Street:
City, State and
City, State and
ZIP Code:
ZIP Code:
STATUS OF FUNDS
11.
PROGRAMS
FUNCTIONS
ACTIVITIES
TOTAL
CLASSIFICATION
(a)
(b)
(c)
a. Administrative expense
$
$
$
$
b. Preliminary expense
c. Land, structures, right-of-way
d. Architectural engineering basic fees
e. Other architectural engineering fee
f. Project inspection fees
g. Land development
h. Relocation expense
i. Relocation payments to individuals
and businesses
j. Demolition and removal
k. Construction and project improvement cost
l. Equipment
m. Miscellaneous cost
n. Total cumulative to date (sum of lines a thru m)
o. Deductions for program income
p. Net cumulative to date (line n minus line o)
q. Federal share to date
r. Rehabilitation grants (100% reimbursement)
s. Total Federal share (sum of lines q and r)
t. Federal payments previously requested
u. Amount requested for reimbursement
$
$
$
$
v. Percentage of physical completion of project
%
%
%
%
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL
DATE REPORT SUBMITTED
12. CERTIFICATION
I certify that to the best of my knowledge and
a. RECIPIENT
TYPED OR PRINTED NAME AND TITLE
TELEPHONE (Area code,
belief the billed costs or disbursements are
number, and extension)
in accordance with the terms of the project
and that the reimbursement represents the
Federal share due which has not been
SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL
DATE SIGNED
previously requested and that an inspection
has been performed and all work is in
b. REPRESENTATIVE
accordance with the terms of the award.
CERTIFYING TO LINE 11V
TYPED OR PRINTED NAME AND TITLE
TELEPHONE (Area code,
number, and extension)
STANDARD FORM 271 (Rev. 7-97)
AUTHORIZED FOR LOCAL REPRODUCTION
Prescribed by OMB Circular A-102 and A-110
PREVIOUS EDITION USABLE
271-103

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