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



### TOTAL (a) (c) (b) 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 forseparate 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. Theamount 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 tothird 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 thisaccount; therebyreflecting netamounts 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 improvementssuch assewers, 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 notspecifically mentioned above. Enter the total cumulative amount to date which should be the sum of lines a through m. Enter thetotal 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. Ifdifferent, 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
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6

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11

11a

11b

11c
11d 11e
11f 11g

11h

11i 11j

11k

11l

11m
11n
11o

11p 11q 11r

11t

11u

12a

12b