OMB Number: 4040-0012 

Expiration Date: 01/31/2025

ADVANCE

a. "X" one or both boxes

REIMBURSEMENT

b. "X" the applicable box

FINAL

PARTIAL

2. BASIS OF REQUEST

CASH

REQUEST FOR ADVANCE ACCRUAL

OR REIMBURSEMENT

1. 

TYPE OF 

PAYMENT 

REQUESTED

3. FEDERAL SPONSORING AGENCY AND ORGANIZATIONAL

ELEMENT TO WHICH THIS REPORT IS SUBMITTED

U.S. Election Assistance Commission EACHAVCP23P20

4. FEDERAL GRANT OR OTHER IDENTIFYING NUMBER

ASSIGNED BY FEDERAL AGENCY

5. PARTIAL PAYMENT REQUEST

NUMBER FOR THIS REQUEST

1 01-2345678

6. EMPLOYER IDENTIFICATION

NUMBER

EACHAVCP23P20

7. FINANCIAL ASSISTANCE

IDENTIFICATION NUMBER

02/01/2024 03/31/2024

8. PERIOD COVERED BY THIS REQUEST

From: To: 

Name: Poll Worker University

9. RECIPIENT ORGANIZATION

Street1:

Street2:

City:

State:

ZIP / Postal Code:

Country:

County:

Province:

1010 University Drive

College City

DC: District of Columbia

USA: UNITED STATES

12345-6789

Name: Poll Worker University Foundation

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

Street1:

Street2:

City:

State:

ZIP / Postal Code:

Country:

County:

Province:

2020 University Parkway

University Park

DC: District of Columbia

USA: UNITED STATES

98765-4321
11. COMPUTATION OF AMOUNT OF REIMBURSEMENTS/ADVANCES REQUESTED

PROGRAMS/FUNCTIONS/

ACTIVITIES

(a) Poll Worker Grant

Program

(b) (c)

10,000.00

a. Total program

outlays to date 03/31/2024

(As of date)

10,000.00

TOTAL

0.00

b. Less: Cumulative program

income 0.00

10,000.00

c. Net program outlays (Line a

minus line b) 10,000.00

d. Estimated net cash outlays for

advance period

e. Total (Sum of lines c & d) 10,000.00 10,000.00

1,000.00 1,000.00

f. Non-Federal share of amount

on line e

g. Federal share of amount on

line e 9,000.00 9,000.00

h. Federal payments previously

requested 0.00 0.00

i. Federal share now requested

(Line g minus line h)

9,000.00 9,000.00

j. Advances required

by month, when

requested by Federal

grantor agency for

use in making

prescheduled

advances

1st month

2nd month

3rd month

$ $ $ $

c. Amount requested (Line a minus line b)

13. CERTIFICATION

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

$

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

04/01/2024

DATE REQUEST SUBMITTED

TYPED OR PRINTED NAME AND TITLE

Prefix: First Name: Tracy Middle Name:

Last Name: Provost Suffix:

Title: University President

TELEPHONE (AREA CODE, NUMBER, EXTENSION)

202-867-5309

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:

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 

Item Entry

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.

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 

in- kind 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.

Item Entry