OMB Number: 4040-0012 

Expiration Date: 01/31/2025

REQUEST FOR ADVANCE 

OR REIMBURSEMENT

1. 

TYPE OF 

PAYMENT 

REQUESTED

a. "X" one or both boxes

ADVANCE

REIMBURSEMENT

b. "X" the applicable box

FINAL

PARTIAL

2. BASIS OF REQUEST

CASH

ACCRUAL

3. FEDERAL SPONSORING AGENCY AND ORGANIZATIONAL 

ELEMENT TO WHICH THIS REPORT IS SUBMITTED

USDA - AMS - TM - (Select either FMPP or LFPP) 

4. FEDERAL GRANT OR OTHER IDENTIFYING NUMBER 

ASSIGNED BY FEDERAL AGENCY

 Example: AM23FMPPINXXXX

5. PARTIAL PAYMENT REQUEST 

NUMBER FOR THIS REQUEST

Request 1

6. EMPLOYER IDENTIFICATION 

NUMBER

Example: 00-XXXXXXX

7. FINANCIAL ASSISTANCE 

IDENTIFICATION NUMBER

8. PERIOD COVERED BY THIS REQUEST

From: To: xx/xx/xxxx xx/xx/xxxx

9. RECIPIENT ORGANIZATION

Name: ABC, LLC

Street1: 123 Big Street

Street2:

City: Washington 

County:

State: DC: District of Columbia

Province:

Country: USA: UNITED STATES

ZIP / Postal Code: 20250

10. PAYEE (Where check is to be sent if different than item 9)

Name:

Street1:

Street2:

City:

County:

State:

Province:

Country:

ZIP / Postal Code:
11. COMPUTATION OF AMOUNT OF REIMBURSEMENTS/ADVANCES REQUESTED

PROGRAMS/FUNCTIONS/ (a) Example: FY23 FMLFPP (b) (c)

ACTIVITIES Award

TOTAL

(As of date) a. Total program 

outlays to date xx/xx/xxxx $ 20,978.36 $ $ $ 20,978.36

b. Less: Cumulative program 

income

c. Net program outlays (Line a 20,978.36 20,978.36 minus line b)

d. Estimated net cash outlays for 

advance period 0.00 0.00

e. Total (Sum of lines c & d) 20,978.36 20,978.36

f. Non-Federal share of amount 

on line e 6,000.00 6,000.00

g. Federal share of amount on 

line e 14,978.36 14,978.36

h. Federal payments previously 

requested 8,278.36 8,278.36

i. Federal share now requested 6,700.00 6,700.00 (Line g minus line h)

j. Advances required 1st month by month, when 

requested by Federal 

grantor agency for 2nd month

use in making 

prescheduled 3rd month

advances

12. ALTERNATE COMPUTATION FOR ADVANCES ONLY

a. Estimated Federal cash outlays that will be made during period covered by the advance $

b. Less: Estimated balance of Federal cash on hand as of beginning of advance period

c. Amount requested (Line a minus line b) $

13. CERTIFICATION

I certify that to the best of my knowledge and belief the data on the reverse are correct and that all outlays were made in accordance with the grant 

conditions or other agreement and that payment is due and has not been previously requested.

SIGNATURE OR AUTHORIZED CERTIFYING OFFICIAL DATE REQUEST SUBMITTED

xx/xx/xxxx

TYPED OR PRINTED NAME AND TITLE

Prefix: First Name: Middle Name:

Last Name: Suffix:

Title:

TELEPHONE (AREA CODE, NUMBER, EXTENSION)

This space for agency use

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.
INSTRUCTIONS

Please type or print legibly. Items 1, 3, 5, 9, 10, 11e, 11f, 11g, 11i, 12 and 13 are self-explanatory; specific instructions 

for other items are as follows:

Item Entry Item Entry

2 Indicate whether request is prepared on cash or accrued as many additional forms as needed and indicate page 

expenditure basis. All requests for advances shall be number in space provided in upper right; however, the 

prepared on a cash basis. summary totals of all programs, functions, or activities 

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

4 Enter the Federal grant number, or other identifying number 

assigned by the Federal sponsoring agency. If the advance 11a Enter in "as of date," the month, day, and year of the 

or reimbursement is for more than one grant or other ending of the accounting period to which this amount 

agreement, insert N/A; then, show the aggregate amounts. applies. Enter program outlays to date (net of refunds, 

On a separate sheet, list each grant or agreement number rebates, and discounts), in the appropriate columns. For 

and the Federal share of outlays made against the grant or requests prepared on a cash basis, outlays are the sum 

agreement. of actual cash disbursements for goods and services, 

the amount of indirect expenses charged, the value of 

6 Enter the employer identification number assigned by the in- kind contributions applied, and the amount of cash 

U.S. Internal Revenue Service, or the FICE (institution) advances and payments made to subcontractors and 

code if requested by the Federal agency. subrecipients. For requests prepared on an accrued 

expenditure basis, outlays are the sum of the actual 

cash disbursements, the amount of indirect expenses 7 This space is reserved for an account number or other incurred, and the net increase (or decrease) in the identifying number that may be assigned by the recipient. amounts owed by the recipient for goods and other 

property received and for services performed by 8 Enter the month, day, and year for the beginning and employees, contracts, subgrantees and other payees. ending of the period covered in this request. If the request 

is for an advance or for both an advance and 

11b Enter the cumulative cash income received to date, if reimbursement, show the period that the advance will requests are prepared on a cash basis. For requests cover. If the request is for reimbursement, show the period prepared on an accrued expenditure basis, enter the for which the reimbursement is requested. cumulative income earned to date. Under either basis, 

enter only the amount applicable to program income Note: The Federal sponsoring agencies have the option of that was required to be used for the project or program requiring recipients to complete items 11 or 12, but not by the terms of the grant or other agreement. both. Item 12 should be used when only a minimum 

amount of information is needed to make an advance 

11d Only when making requests for advance payments, and outlay information contained in item 11 can be enter the total estimated amount of cash outlays that obtained in a timely manner from other reports. will be made during the period covered by the advance.

11 The purpose of the vertical columns (a), (b), and (c) is to 13 Complete the certification before submitting this request. provide space for separate cost breakdowns when a 

project has been planned and budgeted by program, 

function, or activity. If additional columns are needed, use