Form 4923 - Economic Vitality Incentive Program (Evip) Grant Payment Request Page 2
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2Form 4923, Page 2
PART 4: FOR ORTA USE ONLY
$
$
Grant Amount:
Total Expenditures this Request
(
)
(
)
Less Previous Amount:
Less Ineligible Costs or Reductions
$
$
REMAINING GRANT AMOUNT
TOTAL REIMBURSEMENT AMOUNT
Payments will not be processed without expenditure documentation and the required signature.
Return this completed request along with all documentation to:
Michigan Department of Treasury
Office of Revenue and Tax Analysis
PO Box 30722
Lansing, MI 48909
Instructions for Form 4923
Economic Vitality Incentive Program Grant Payment Request
The numbers listed below coincide with the numbers on the payment request form. Lines not listed are explained on the form.
PART 1: PROJECT INFORMATION
1. Grant Number: Fill in the respective grant number that was assigned by the Michigan Department of Treasury.
2. Project Title: Short name that was used on the grant application to describe the project.
3. Request Number: Identify the number of this payment request.
4. Period Start Date: Indicate the period start date of this payment request.
5. Period End Date: Indicate the period end date of the payment request.
6. Request Type: Check whether this is a partial or the final payment request.
7. Primary Local Unit FEIN: Federal Employer Identification Number that is issued by the Internal Revenue Service.
8. Primary Local Unit Name: The primary Local Unit that has the authority and the responsibility for the administration of the project in accordance
with the project conditions. For example, “City of Blank” is acceptable.
9. Telephone Number: Phone number, including area code, of the Primary Local Unit.
10. Payment Mailing Address: Street number and name, including suite number if applicable, of the Primary Local Unit.
PART 2: EXPENDITURE DETAIL
Lines 11-17 Enter eligible costs incurred to date for each budget category. Entries in this section must be rounded to the nearest dollar.
Column A: These are the approved budget categories from the Final Grant Award Letter.
Column B: Enter the total amount(s) incurred for the period for each budget category.
Column C: These are the percentages of funding approved for each budget category.
Column D: Allowable amount(s) incurred and requested this period (Column B times Column C).
Column E: Show the cumulative amount(s) to date (from project inception).
NOTE: YOU MAY SUBMIT NO MORE THAN ONE REQUEST FOR DISBURSEMENT DURING A CALENDAR MONTH.
MAIL DOCUMENTATION TO SUPPORT THE INCURRED COSTS INCLUDING COPIES OF THE ORIGINAL INVOICES,
CANCELLED CHECKS, AND ANY OTHER REPORT(S) THAT WOULD SUPPORT THE REQUEST.
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