Request For Advance Or Reimbursement - U.s. Department Of Labor
Download a blank fillable Request For Advance Or Reimbursement - U.s. Department Of Labor in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Request For Advance Or Reimbursement - U.s. Department Of Labor with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2OMB #: 3135-0112 Expires 12/31/19
Request for Advance
E-mail this form to Grants & Contracts Office at grants@arts.gov,
or Reimbursement
or via fax to 202/682-5610 or 202/682-5609.
If you need additional assistance, call 202/682-5403.
(Payment Request Form for Cooperative Agreements)
1. National Endowment for the Arts
2. Cooperative Agreement #: DCA -
3. Type of payment requested:
4. Basis of request:
5. Payment Request:
a.
Advance
b.
Final
Cash
#
Reimbursement
Partial
Accrued Expenditures
6. Taxpayer Identification Number:
7. Period covered by this request:
(or EIN)
(month/day/year)
–
From:
/
/
To:
/
/
.
8. Cooperator:
(Official IRS name/mailing address)
Reminders:
a. Authorizing Official. This form must be submitted by an
Authorizing Official.
b. Progress report. You must provide a progress report in
Section 10 when the cumulative amount requested exceeds
9. Computation of amount requested:
two-thirds of your award amount.
a. Total project outlays to date
c. SAM.gov. You must have an active registration in SAM (the
$
10.
(As of
/
/
)
System for Award Management) to receive payment.
b. Estimated net cash outlays
d. Payment. Funds can only be remitted via Electronic Funds
$
needed for 30-day advance
Transfer. You must complete #12 below for an Automated
Clearing House (ACH) payment. This information must be
c. Total (a plus b)
$
0
provided on every payment request; missing or incorrect
d. Recipient share of amount
numbers will delay your request and/or prevent your bank
$
from crediting your account.
on line c
e. Endowment share of
e. Labor Assurances. By submitting this request, you are also
$
0
amount on line c (c minus d)
certifying to the
Assurances as to Labor Standards
outlined on
page 2 of this form.
f. Endowment payments
$
previously requested
See the
General Terms & Conditions
and
Reporting Requirements
g. Endowment share now
for additional guidance.
$
0
requested (e minus f)
10. Progress report:
Please respond in the space provided or attach to this form. Do NOT submit under separate cover.
11. Authorizing Official:
By signing this report, I certify to the best of my knowledge and belief that the report is true, complete and
accurate, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and
conditions of the Federal award. [Certification continues on
page
two.]
Name:
Date:
Title:
Phone:
(
)
-
ext.
Contact Person:
Phone:
(
)
-
ext.
Contact E-mail:
Fax:
(
)
-
12. Bank Information:
For Agency use only:
(REQUIRED)
Name of Bank
Reviewed by
Initials / Date
City/State
–
–
RTN #
Approved by
.
Name / Date
Bank Account #
• Finance, Use this Date:
checking
savings
Revised 11/17/14
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Ee-1 - Worker's Claim For Benefits Under The Energy Employees Occupational Illness Compensation Program Act - U.s. Department Of Labor, Office Of Workers' Compensation Programs
Legal
Related Categories
Parent category: Legal