Document ID: EPA-HQ-OARM-2011-0997-0010
Agency: epa
Document Type: Supporting & Related Material
Title: 
Posted Date: 2015-05-14T04:00Z

EPA   United States Environmental Protection Agency

    Contractor's Cumulative Claim and Reconciliation	

OMB No. 2030 – 0016

Expiration Date: XX/XX/XX

1. Contractor's Address (include zip code)	2. Contract No.

3. Total amounts claimed under this contract (less disallowances
concurred by the contractor and disallowances not subject to appeal) and
approved on Public Vouchers Nos.	to	(including completion vouchers).

Item	Amount

Direct Labor	$

Direct Material and Supplies	$

Equipment	$

Travel	$

Subcontract Costs	$

Other Direct Costs	$

Consultant Fees	$

Fixed Fee	$

Indirect Costs (Total From Section 4)	$

Total Amount Claimed	$

4. Reconciliation of Indirect Costs Claimed.  Record the amount of
indirect costs calculated, for each cost center, using negotiated final
indirect cost rate(s).  Use provisional rate(s) if final rates are not
negotiated for any fiscal year period(s).  Use the reverse side of this
form, if necessary, to display all years and cost centers.

	Cost Center	Cost Center	Cost Center	Cost Center	Cost Center

FY

	Base

	Rate

	Indirect Costs

	FY

	Base

	Rate

	Indirect Costs

	FY

	Base

	Rate

	Indirect Costs

	Totals

	No monies or other benefits may be paid unless this report is completed
and filed as required in the EPA billing instructions. 

I certify that the information provided on this form and attachments
thereto are accurate and complete.  I acknowledge that any knowingly
false or misleading information may be punishable by fine and/or
imprisonment under applicable law.

Name and Title (Print or Type)	Signature	Date



Paperwork Reduction Act Notice

The public reporting and recordkeeping burden for this collection of
information is estimated to average 6.3 hours per response. Send
comments on the Agency's need for this information, the accuracy of the
provided burden estimates, and any suggested methods for minimizing
respondent burden, including through the use of automated collection
techniques to the Director, Collection Strategies Division, U.S.
Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW,
Washington, D.C. 20460. Include the OMB control number in any
correspondence. Do not send the completed form to this address.

	Cost Center	Cost Center	Cost Center	Cost Center	Cost Center

FY

	Base

	Rate

	Indirect Costs

	FY

	Base

	Rate

	Indirect Costs

	FY

	Base

	Rate

	Indirect Costs

	FY

	Base

	Rate

	Indirect Costs

	FY

	Base

	Rate

	Indirect Costs

	Totals

	

No monies or other benefits may be paid unless this report is completed
and filed as required in the EPA billing instructions.