Spreadsheet: 14fc02be-6793-4625-b363-44551e5716e6
Sheet: Sheet1

F O R M   P R 1 | C o m m o n w e a l t h   o f   P e n n s y l v a n i a
T Y P E   2 | R e d e v e l o p m e n t   A s s i s t a n c e   C a p i t a l   P r o g r a m
2010-05-01 00:00:00 | A P P L I C A T I O N   F O R   P A Y M E N T   -   R E Q U E S T   N O . ________
GRANTEE NAME |  |  |  | SUB-GRANTEE NAME
Street Address |  |  |  | PROJECT NAME
City, State, Zip Code |  |  |  | Contract No. ME 300 - |  | Contract No. OB-RACP -
SAP Vendor Number ** |  |  |  | Grant Contract Period |  | to
**  Register by calling [NAME] at (717) 346-2676 or toll free at (877) 435-7363 |  |  |  | Legislative Authorization Date |  | Payment Request Date
COST CATEGORIES | D I S T R I B U T I O N   O F   E S T I M A T E D   C O S T S                                                                                                      (Provide Distribution According to Approved RDA Forms) |  |  | UPDATED COST | C O S T S   P A I D   T O   D A T E
For Line Items & Distribution of Costs,  See Approved RDA Forms in Grant Agreement | Costs Distributed to RACP | Costs Distributed to MATCH | TOTAL | ESTIMATE | Costs Attributed to RACP | Costs Attributed to LOCAL MATCH | Total Costs                                                       Paid to Date
Line Items | 1A | 1B | 1C | 2 | 3A | 3B | 3C
1. Operations / Maintenance | Typical Match |  |  |  | Typical Match
2. Administration | Typical Match |  |  |  | Typical Match
3. Legal | Typical Match |  |  |  | Typical Match
4. Financing / Accounting | Typical Match |  |  |  | Typical Match
5. Interest During Construction
6. Architectural / Engineering | Typical Match |  |  |  | Typical Match
7. Permits
8. Land
9A. Construction (Complete PR1A)
9B.  Contingency
10.  Other
TOTAL
[NAME] | 1 |  |  |  | 1
 | COMPUTATION OF ELIGIBLE RACP AMOUNT (Select the Lower of the Following) |  |  |  |  | ELIGIBLE RACP AMOUNT
COSTS ATTRIBUTED TO RACP | TOTAL of COLUMN 3A
APPLY DISTRIBUTION FACTOR | MATCH EXPENSES PAID   divided by   FACTOR
AVAILABLE PER ACCUM SCHEDULE | MONTHLY ACCUM.              times      MONTH NO.
THE GRANTEE CERTIFIES THE FOLLOWING: |  | P A Y M E N T  S C H E D U L E  T O  B E  C O M P L E T E D  B Y  T H E  C O M M O N W E A L T H
*  All invoices included in this request have been paid. |  | A V A I L A B L E   F U N D I N G |  | R E T A I N A G E |  | P A Y M E N T S   (A C H)       YES          NO
*  Appropriate documentation as evidence of payment is included. |  | Accumulation per Sched. |  | Previous Requests |  | ELIGIBLE RACP AMT.
*  All costs included in this request are accurate. |  | Previous Payments |  | This Request |  | Previous Requests
*  All costs included in this request are only for work performed on |  | Available This Request |  | Returned |  | This Request
the project that is defined in the Grant Agreement. |  |  |  | [NAME]
[NAME] REQUESTED | YES         NO | For Invoices Paid From           ___________________________  To  ________________________ |  |  |  | SAP CODING
GRANTEE BANK INFORMATION:                                 Bank Name |  |  |  |  |  | SAP Document # | 41000
Full Account Number of CVMU Registered Bank |  | NOTE: |  |  |  | SAP Fund Center # | 2432002000
 |  | BY SIGNING BELOW, THE OFFICE OF THE BUDGET CERTIFIES THAT ALL SPECIAL |  |  |  | SAP GL # | 6600400
 |  | CONDITIONS LISTED IN APPENDIX B OF THE GRANT AGREEMENT HAVE BEEN SATISFIED.
 |  |  |  |  |  | SAP Fund # (Line    ) | 30166      000  -
Signature of Grantee's Authorized Representative           Date |  | Signature of Commonwealth's Authorized Official |  |  | Date | SAP Fund # (Line    ) | 30166      000  -