OUTLAY REPORT AND REQUEST FOR REIMBURSEMENT PAGE O F

FOR CONSTRUCTION PROGRAMS PAGES

 1. TYPE OF REQUEST 2. BASIS OF REQUEST

(See instructions on back)

3. FEDERAL SPONSORING AGENCY AND ORGANIZATIONAL ELEMENT TO 4. FEDERAL GRANT OR OTHER 5. PARTIAL PAYMENT REQUEST NO.

 WHICH THIS REPORT IS SUBMITTED IDENTIFYING NUMBER

 ASSIGNED BY FEDERAL AGENCY

6. EMPLOYER IDENTIFICATION 7. RECIPIENT'S ACCOUNT NUMBER PERIOD COVERED BY THIS REQUEST

 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:

11. STATUS OF FUNDS

PROGRAMS -- FUNCTIONS -- ACTIVITIES

CLASSIFICATION

 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

12. CERTIFICATION DATE REPORT SUBMITTED

TELEPHONE (Area code, number, 

and extension)

DATE SIGNED

TELEPHONE (Area code, number, 

and extension)

AUTHORIZED FOR LOCAL REPRODUCTION STANDARD FORM 271 (Rev. 7-97)

PREVIOUS EDITION USABLE Prescribed by OMB Circular A-102 and A-110

271-103

FINAL PARTIAL CASH ACCRUAL

(a) (b) (c) TOTAL

OMB APPROVAL NO. 0348-0002

$ $ $ $

$ $ $ $

% % % %

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

TYPED OR PRINTED NAME AND TITLE

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

TYPED OR PRINTED NAME AND TITLE

a. RECIPIENT

b. REPRESENTATIVE 

CERTIFYING TO LINE 11V

I certify that to the best of my knowledge and

belief the billed costs or disbursements are

in accordance with the terms of the project

and that the reimbursement represents the

Federal share due which has not been

previously requested and that an inspection

has been performed and all work is in

accordance with the terms of the award.
INSTRUCTIONS

 Please type or print legibly. Items 3, 4, 5, 8, 9, 10, 11s and 11v are self explanatory; specific instructions for other items are as

 follows:

Item Entry Item Entry

STANDARD FORM 271 (Rev. 7-97) Back

Public reporting burden for this collection of information is estimated to average 60 minutes per response, including time for reviewing instructions,

searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments

regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of

Management and Budget, Paperwork Reduction Project (0348-0004), Washington, DC 20503.

PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET.

SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.

Mark the appropriate box. If the request is final, the amounts

billed should represent the final cost of the project.

Show whether amounts are computed on an accrued

expenditure or cash disbursement basis.

Enter the Employer Identification Number (EIN) assigned

by the U.S. Internal Revenue Service or FICE (institution)

code if requested by the Federal agency.

This space is reserved for an account number or other

identifying number that may be assigned by the recipient.

The purpose of vertical columns (a) through (c) is to

provide space for separate cost breakdowns when a large

project has been planned and budgeted by program,

function or activity. If additional columns are needed, use

as many additional forms as needed and indicate page

number in space provided in upper right; however, the

summary totals of all programs, functions, or activities

should be shown in the "total" column on the first page.

All amounts are reported on a cumulative basis.

Enter amounts expended for such items as travel, legal

fees, rental of vehicles and any other administrative

expenses. Include the amount of interest expense when

authorized by program legislation. Also show the amount

of interest expense on a separate sheet.

Enter amounts pertaining to the work of locating and

designing, making surveys and maps, sinking test holes,

and all other work required prior to actual construction.

Enter all amounts directly associated with the acquisition

of land, existing structures and related right-of-way.

Enter basic fees for services of architectural engineers.

Enter other architectural engineering services. Do not

include any amounts shown on line d.

Enter inspection and audit fees of construction and related

programs.

Enter all amounts associated with the development of

land where the primary purpose of the grant is land

improvement. The amount pertaining to land development

normally associated with major construction should be

excluded from this category and entered on line k.

Enter the dollar amounts used to provide relocation

advisory assistance and net costs of replacement housing

(last resort). Do not include amounts needed for

relocation administrative expenses; these amounts should

be included in amounts shown on line a.

Enter the amount of relocation payments made by the

recipient to displaced persons, farms, business concerns,

and nonprofit organizations.

Enter gross salaries and wages of employees of the

recipient and payments to third party contractors directly

engaged in performing demolition or removal of

structures from developed land. All proceeds from the

sale of salvage or the removal of structures should be

credited to this account; thereby reflecting net amounts if

required by the Federal agency.

Enter those amounts associated with the actual

construction of, addition to, or restoration of a facility.

Also, include in this category, the amounts for project

improvements such as sewers, streets, landscaping, and

lighting.

Enter amounts for all equipment, both fixed and

movable, exclusive of equipment used for construction.

For example, permanently attached laboratory tables,

built-in audio visual systems, movable desks, chairs,

and laboratory equipment.

Enter the amounts of all items not specifically mentioned

above.

Enter the total cumulative amount to date which should

be the sum of lines a through m.

Enter the total amount of program income applied to the

grant or contract agreement except income included on

line j. Identify on a separate sheet of paper the sources

and types of the income.

Enter the net cumulative amount to date which should be

the amount shown on line n minus the amount on line o.

Enter the Federal share of the amount shown on line p.

Enter the amount of rehabilitation grant payments made

to individuals when program legislation provides 100

percent payment by the Federal agency.

Enter the total amount of Federal payments previously

requested, if this form is used for requesting

reimbursement.

Enter the amount now being requested for

reimbursement. This amount should be the difference

between the amounts shown on lines s and t. If different,

explain on a separate sheet.

To be completed by the official recipient official who is

responsible for the operation of the program. The date

should be the actual date the form is submitted to the

Federal agency.

To be completed by the official representative who is

certifying to the percent of project completion as

provided for in the terms of the grant or agreement.

1

2

6

7

11

11a

11b

11c

11d

11e

11f

11g

11h

11i

11j

11k

11l

11m

11n

11o

11p

11q

11r

11t

11u

12a

12b