Spreadsheet: 01491045-9521-4d69-aebf-fbbee37feed1
Sheet: Sheet1

State of Alaska | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Reimbursable Services Agreement | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12 | Unnamed: 13 | Unnamed: 14 | Unnamed: 15 | Unnamed: 16 | ORIGINAL | Unnamed: 18 | Unnamed: 19 | Unnamed: 20 | AMENDMENT # | Unnamed: 22 | Unnamed: 23
Payment Process
 |  | Execute [NAME] (145-90 or 145-95) |  |  |  |  |  |  |  |  | Agency Journal Entry (430-40) |  |  |  |  |  |  | Other
Requesting Agency |  |  |  |  |  | BRU |  |  |  |  |  |  | Component |  |  |  |  |  |  |  |  | ADN #
Servicing Agency |  |  |  |  |  | BRU |  |  |  |  |  |  | Component |  |  |  |  |  |  |  |  | ADN #
I.   Project or program title:
II.  The servicing agency agrees to provide the requesting agency with the following service(s):
(Answer who, what, where, when, why and how cost estimates are derived.  Use attachment if necessary.)
REQ Program Contact/Phone: |  |  |  |  |  |  |  |  |  |  | SVC Program Contact/Phone:
III. Terms and mechanics of reimbursement: |  |  |  |  |  |  |  |  |  |  | Billing Address:
 |  | Payment upon approval
 |  | Payment upon receipt of inter-agency billing
 |  | Payment upon completion of service(s)
 |  | Other (Specify)
Commencement date |  |  |  |  |  |  | Completion date |  |  |  |  |  |  | Billing RD code |  |  |  |  |  |  | Phone #
IV. Servicing agency cost based on: |  |  |  |  |  |  |  |  | Itemized costs of service(s) provided
 |  |  |  |  |  |  |  |  | Cost allocation schedule (description of allocation methodology must be attached)
V.  Schedule of maximum costs to be incurred by the Servicing Agency:
 |  |  |  | Original Agreement |  |  |  |  | Previous Amendment(s) |  |  |  |  |  | This Amendment |  |  |  |  | Total
 |  |  | Personal Services | $ |  |  |  |  | $ |  |  |  |  | $ |  |  |  |  | $ | 0
 |  |  | Travel | $ |  |  |  |  | $ |  |  |  |  | $ |  |  |  |  | $ | 0
 |  |  | Services | $ |  |  |  |  | $ |  |  |  |  | $ |  |  |  |  | $ | 0
 |  |  | Commodities | $ |  |  |  |  | $ |  |  |  |  | $ |  |  |  |  | $ | 0
 |  |  | Capital Outlay | $ |  |  |  |  | $ |  |  |  |  | $ |  |  |  |  | $ | 0
 |  |  | Grants and Benefits | $ |  |  |  |  | $ |  |  |  |  | $ |  |  |  |  | $ | 0
 | Other |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0
 |  |  | Total | $ | 0 |  |  |  | $ | 0 |  |  |  | $ | 0 |  |  |  | $ | 0
 |  | Servicing Agency may not change line items without approval of Requesting Agency
VI. Budgeting and Accounting Information :
Requesting Agency Appropriation |  |  |  |  |  |  |  |  |  |  | Capital |  | Operating
 | If Operating, is item on Inter-Agency Services Report? |  |  |  |  |  |  |  |  |  | No |  | Yes, on detailed Budget Page
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | ([NAME]:  [NAME]   Ch   SLA   Pg   Ln   OR RPL # [NAME])
Financial coding to be charged |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Appropriation Cite
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Appropriation Cite
Open Item # or Batch # (RS, EN, or AJE) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Date funds lapse
Federal funds |  |  |  | No |  | Yes, Amount |  |  |  |  |  |  |  |  |  |  |  | ARRA funds |  | No |  |  | Yes
Federal Pass Through: |  |  |  | YES |  | NO |  |  |  |  |  |  |  |  |  |  |  | ARRA Reporting to be done by: |  | Requesting |  |  | Servicing
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  | If the RSA includes ARRA funds, it can not include other types of funding.
Federal Agency/Program/CFDA/Grant/Contract No. |  |  |  |  |  |  |  |  |  |  |  |  |  |  | ARRA RSAs must stand alone.
Servicing Agency Authorization
 |  | Is this agreement using budgeted authorization? |  |  |  |  |  |  |  |  | No |  |  | Yes
 |  | Is item on Restricted Revenue Report? |  |  |  |  |  |  |  |  | No |  |  | Yes, on detailed Budget Page
AR |  |  | CC |  |  |  | RR |  |  |  | Other
AR |  |  | CC |  |  |  | RR |  |  |  | Other
VII: Approvals & Certification: The requesting agency and servicing agency agree to the terms and conditions above.  In addition, the requesting agency certifies that sufficient funds are encumbered to pay this obligation or that there is sufficient unencumbered balance in the appropriation cited to cover this obligation.  I am aware that to knowingly make or allow false entries or alterations on a public record, or knowingly destroy, mutilate, suppress, conceal, remove or otherwise impair the verity, legibility or availability of a public record constitutes tampering with public records punishable under AS 11.56.815-820.  Other disciplinary action may be take up to and including dismissal.
Requesting Agency Authorized Signature |  |  |  |  |  |  |  |  | Printed Name |  |  |  |  |  |  |  |  | Date
Servicing Agency Authorized Signature |  |  |  |  |  |  |  |  | Printed Name |  |  |  |  |  |  |  |  | Date
OMB Authorized Signature (as applicable) |  |  |  |  |  |  |  |  | Printed Name |  |  |  |  |  |  |  |  | Date
02-098 (OMB Rev. August 2009)