**Cost Share No Paper Check Policy Exception Request**

Directions: Please complete, print, **sign**,****and email (along with any necessary or elective documentation supporting your request) to vista@americorps.gov. If you choose to hand-write, rather than type and print your information, please print clearly. AmeriCorps will make every effort to respond to the email address provided below, as well as to the sponsor’s authorized representative and the project director, within 10 business days.

**Part 1: Sponsor identification.**

Cost Share Sponsor Name (this is the legal name of the organization which has entered into a cost share memorandum of agreement with AmeriCorps):Click or tap here to enter text.

Sponsor EIN #: Click or tap here to enter text.	Grant #(s): Click or tap here to enter text.

Sponsor Contact Name: Click or tap here to enter text.

Contact Phone #: Click or tap here to enter text.	Contact Email Address: Click or tap here to enter text.
**Part 2: What length of exception are you requesting? Select one of the following:**

☐Annual, effective through: Click or tap to enter a date.	☐Temporary, effective through: Click or tap to enter a date.

**Part 3: Investigating technical issues.**

Contact the AmeriCorps Hotline at 800-942-2677, or https://questions.americorps.gov/ for technical assistance before requesting an exception based on a technical issue. *It will be necessary to provide the ticket number assigned to your issue by the AmeriCorps Hotline*, if you are requesting an exception based on a technical issue in Part 4 below.

**Part 4: Why are you requesting an exception to the Cost Share No Paper Check Policy? Check all that apply.**

A. ☐**Written rule/law/regulation/policy prohibiting**one or more elements of the electronic payment process using the Pay Now functionality in eGrants. *Attach a copy of the written rule/law/regulation/policy to the request.*

B. ☐**Technical issue**preventing successful electronic payment using the Pay Now functionality in eGrants.

**Explain/describe.***If the space in this field is inadequate, please continue on a separate document, and attach it to the email submission.*

What ticket number was assigned to your issue when you contacted the AmeriCorps Hotline for technical assistance? Click or tap here to enter text.

C. ☐**Other good cause,**not based on convenience or preference.

**Explain/describe.***If the space in this field is inadequate, please continue on a separate document, and attach it to the email submission.*

**Part 5: What would make it possible *or easier*for you to make an electronic cost share reimbursement payment?**

**Explain/describe.***If the space in this field is inadequate, please continue on a separate document, and attach it to the email submission.*

By signing below, I certify that I understand that AmeriCorps requires that cost share reimbursements be made electronically using the eGrants Pay Now functionality because it provides for reduced costs; decreased public vulnerability to fraud; and increased accuracy in the posting of payments. I further certify that, to the best of my knowledge and belief, all information contained in this exception request is true and correct and represents the position of the cost share sponsoring organization regarding its ability to make electronic cost share reimbursement payments using the Pay Now functionality in eGrants.

							Click or tap here to enter text.		                      

Signature of Sponsor Representative	Printed Name of Sponsor Representative	Date (mm/dd/yyyy)

***AmeriCorps Staff Use Only***

Date received: _________           ☐ Approved/ ☐ Denied: _________           Effective through: _________

By: Click or tap here to enter text. 	Emailed response to sponsor/Regional Office: Click or tap here to enter text.

(Updated May 2021)

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