OMB APPROVAL NO. PAGE OF

0348-0004 PAGES 

a. "X" one or both boxes 2. BASIS OF REQUEST

 1.

 TYPE OF

 PAYMENT b. "X" the applicable box

(See instructions on back) REQUESTED

3. FEDERAL SPONSORING AGENCY AND ORGANIZATIONAL ELEMENT TO 4. FEDERAL GRANT OR OTHER 5. PARTIAL PAYMENT REQUEST

 WHICH THIS REPORT IS SUBMITTED IDENTIFYING NUMBER ASSIGNED NUMBER FOR THIS REQUEST

 BY FEDERAL AGENCY

6. EMPLOYER IDENTIFICATION 7. RECIPIENT'S ACCOUNT NUMBER 8. 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:

Number Number

and Street: and Street:

City, State City, State

and ZIP Code: and ZIP Code:

11. COMPUTATION OF AMOUNT OF REIMBURSEMENTS/ADVANCES REQUESTED

PROGRAMS/FUNCTIONS/ACTIVITIES

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. 

 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) $

AUTHORIZED FOR LOCAL REPRODUCTION (Continued on Reverse) STANDARD FORM 270 (Rev. 7-97)

Prescribed by OMB Circulars A-102 and A-110

REQUEST FOR ADVANCE

OR REIMBURSEMENT ADVANCE

FINAL PARTIAL

CASH

ACCRUAL

REIMBURSEMENT

Advances required by

month, when requested

by Federal grantor

agency for use in making

prescheduled advances

TOTAL

$ $ $ $

(a) (b) (c)
13. CERTIFICATION

SIGNATURE OR AUTHORIZED CERTIFYING OFFICIAL DATE REQUEST

SUBMITTED

TYPED OR PRINTED NAME AND TITLE TELEPHONE (AREA

CODE, NUMBER,

EXTENSION)

This space for agency use

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

STANDARD FORM 270 (Rev. 7-97) Back

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.

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.

Indicate whether request is prepared on cash or accrued

expenditure basis. All requests for advances shall be

prepared on a cash basis.

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.

Enter the employer identification number assigned by the

U.S. Internal Revenue Service, or the 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.

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.

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.

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.

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.

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.

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.

Complete the certification before submitting this request.

2

4

6

7

8

Note:

11

11a

11b

11d

13