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

4. FEDERAL GRANT OR OTHER IDENTIFYING NUMBER

ASSIGNED BY FEDERAL AGENCY

5. PARTIAL PAYMENT REQUEST

NUMBER FOR THIS REQUEST

6. EMPLOYER IDENTIFICATION

NUMBER

7. FINANCIAL ASSISTANCE

IDENTIFICATION NUMBER

8. PERIOD COVERED BY THIS REQUEST

From: To:

9. RECIPIENT ORGANIZATION

Name: 

Street1: 

Street2:

City: 

County: 

State: 

Province: 

Country:

ZIP / Postal Code:

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/ 

ACTIVITIES

(a) (b) (c)

TOTAL

a. Total program (As of date)

outlays to date $ $ $ $

b. Less: Cumulative program

income

c. Net program outlays (Line a

minus line b)

d. Estimated net cash outlays for

advance period

e. Total (Sum of lines c & d)

f. Non-Federal share of amount

on line e

g. Federal share of amount on

line e

h. Federal payments previously

requested

i. Federal share now requested

(Line g minus line h)

j. Advances required

by month, when

requested by Federal

grantor agency for

use in making

prescheduled

advances

1st month

2nd month

3rd month

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

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

2 Indicate whether request is prepared on cash or accrued 

expenditure basis. All requests for advances shall be 

prepared on a cash basis.

4 Enter the Federal grant number, or other identifying number 

assigned by the Federal sponsoring agency. If the advance 

or reimbursement is for more than one grant or other 

agreement, insert N/A; then, show the aggregate amounts. 

On a separate sheet, list each grant or agreement number 

and the Federal share of outlays made against the grant or 

agreement.

6 Enter the employer identification number assigned by the

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

code if requested by the Federal agency.

7 This space is reserved for an account number or other 

identifying number that may be assigned by the recipient.

8 Enter the month, day, and year for the beginning and ending 

of the period covered in this request. If the request is for an 

advance or for both an advance and reimbursement, show 

the period that the advance will cover. If the request is for 

reimbursement, show the period for which the 

reimbursement is requested.

Note: The Federal sponsoring agencies have the option of 

requiring recipients to complete items 11 or 12, but not 

both. Item 12 should be used when only a minimum 

amount of information is needed to make an advance 

and outlay information contained in item 11 can be 

obtained in a timely manner from other reports.

11 The purpose of the vertical columns (a), (b), and (c) is to 

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 

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.

Item Entry

11a Enter in "as of date," the month, day, and year of the 

ending of the accounting period to which this amount 

applies. Enter program outlays to date (net of refunds, 

rebates, and discounts), in the appropriate columns. For 

requests prepared on a cash basis, outlays are the sum 

of actual cash disbursements for goods and services, the 

amount of indirect expenses charged, the value of inkind contributions applied, and the amount of cash 

advances and payments made to subcontractors and 

subrecipients. For requests prepared on an accrued 

expenditure basis, outlays are the sum of the actual cash 

disbursements, the amount of indirect expenses incurred, 

and the net increase (or decrease) in the amounts owed 

by the recipient for goods and other property received 

and for services performed by employees, contracts, 

subgrantees and other payees.

11b Enter the cumulative cash income received to date, if 

requests are prepared on a cash basis. For requests 

prepared on an accrued expenditure basis, enter the 

cumulative income earned to date. Under either basis, 

enter only the amount applicable to program income that 

was required to be used for the project or program by the 

terms of the grant or other agreement.

11d Only when making requests for advance payments, enter 

the total estimated amount of cash outlays that will be 

made during the period covered by the advance.

13 Complete the certification before submitting this request.