Periodic Report Cover Sheet - The Nebraska Environmental Trust
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1PERIODIC REPORT
COVER SHEET AND INSTRUCTIONS
Please use this form to file periodic project reports as required in your Trust grant contract. These reports should consist of the
following four parts:
1.
The Cover Sheet. Please complete the information below as requested and submit the SIGNED ORIGINAL with the request
for reimbursement.
2.
Request for Reimbursement. You must submit copies of invoices to document each expense for which you request
reimbursement. Each invoice must contain the name and address of the vendor, and an itemized list of services or goods with
costs and the dates of service or delivery. If invoices contain non-grant items, clearly note the exceptions. Use the “Summary of
Invoices Submitted for Reimbursement” and list each invoice on the table, providing the information as requested. Be sure the
expenditure description contains sufficient information to determine that the item or activity is a legitimate project expense. The
column “Budget Category” references the categories you created in your contract budget outline: each invoice must identify
which category names it falls under. Copy the table if you need additional reporting space. Attach invoices in the order listed on
the Summary sheet.
3.
Project Narrative. On a separate page(s), describe project activities, partners and results of the project for this period. If
modifications were made to the project, describe the changes and explain why they were necessary. Quantify any results you can,
NRC completes the Project Narrative, including your recycling data as it is reported.
for example, acres restored, pounds recycled, etc.
4.
Report on Matching and In-Kind Expenditures. Use this form to report all resources expended on the project other than those
funded by the Trust. Examples of these costs could include materials, labor, donations, other matching funds or volunteer labor
time.
____________________________________________________________________________________________________________
Project Sponsor:
Fiscal Agent:
Fiscal Agent Address:
(street address, city, state, zip code)
Recycling Equipment Grant
16-210
Project Title:
Project No.:
Reporting Period:
Tax I.D. #
ACH or CHECK
TOTAL AMOUNT REQUESTED FOR THIS PERIOD:
I certify that this report is correct and just; that all expenses were necessary expenses of the project and were incurred in accordance
with the approved grant agreement, including any amendments thereto; and that progress of the work and services under grant contract
is satisfactory and consistent with the amount billed. As the Sponsor named above, or agent thereof, I hereby claim reimbursement
from the STATE OF NEBRASKA for the attached and itemized expenses, for which payment has not previously been made by the
STATE OF NEBRASKA.
DATE:
FOR THE SPONSOR:
Signature
TITLE:
Typed or Printed Name
______________________________________________________________________DATE:____________________________
Nebraska Environmental Trust Signature
Periodic Report Cover Sheet 04/30/12
Phone: 402-471-5409 • Fax: 402-471-8233
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