Form 270 Request for advance Reimbursement

OMB NO 0 9 3 7 - 0 2 0 0
EXCEPTION TO S F 2 7 0 APPROVED BY GSA/OIRM 5 / 8 5
E X P I R A T I O N DATES 0 1 / 3 1 / 2 0 0 0

PMS 2 7 0

-----------------------------------------------------------------------------------I . TYPE OF

REQUEST FOR ADVANCE

.....................................

REIMBURSEMENT
XX
- - ADVANCE
REQUESTED
----------------------------------------------

2.

3.

OR REIMBURSEMENT

PAYMENT

B A S I S OF REQUEST
XX

D I V I S I O N OF PAYMENT MANAGEMENT
DHHS/PHS/OASH/OM/ORM
P.O. BOX 6 0 2 1
ROCKVILLE, MD. 2 0 8 5 2
7-.... R-.-E C I-.P I E N T ORGAN,IZATION
.

--

4.

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O N L Y
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P E R I O D COVERED BY T H I S REQUEST
T0
YEAR)

(MONTH,

DAY,

x

n n

....................................................................................S
10.
CERTIFICATION
....................................................................................
SIGNATURE OF C E R T I F Y I N G O F F I C I A L

I C E R T I F Y THAT TO THE BEST OF
MY KNOWLEDGE AND B E L I E F THE
DATA ABOVE ARE CORRECT AND
THAT A L L OUTLAYS WERE MADE I N
ACCORDANCE W I T H THE GRANT COND I T I O N S OR OTHER AGREEMENT AND
THAT PAYMENT I S DUE AND HAS
NOT BEEN PREVIOUSLY REQUESTED.

..................................................
..................................................
AREA CODE

N O T

T R I M

T H I S

DATE REQUEST
SUBMITTED

TYPED OR P R I N T E D NAME AND T I T L E
TELEPHONE

D O

S

C . AMOUNT REQUESTED ( L I N E A M I N U S B ) FOR

9

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F U N D S

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8 . LESS1 ESTIMATED BALANCE OF FEDERAL CASH ON HAND AS OF

M A R G I N

.

COMPUTATION FOR ADVANCES ONLY
....................................................................................
THRU

YEAR)

E X C E S S

T H I S

O N L Y

9.

FED. CASH OUTLAYS TO BE MADE DURING P E R I O D

N O T

T R I M

ACCRUAL

DAY,

D O

I

5 . PAYEE I D NO.

.........................
6 . ACCT . NO.
..............................................
8.

F U N D S

EIN

.....................................................................................
EST.

n

.........................

CASH

FROM
(MONTH,

A.

n

n

FEDERAL SPONSORING AGENCY!

A

.

-

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NUMBER

EXTENSION

....................................................................................

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PAPERWORK REDUCTION ACT STATEMENT
A FEDERAL AGENCY MAY NOT CONDUCT OR SPONSOR, AND A PERSON I S NOT REQUIRED TO RESPOND TO, A
COLLECTION OF INFORMATION UNLESS I T D I S P L A Y S A CURRENTLY V A L I D OM0 CONTROL NUMBER. P U B L I C
REPORTING BURDEN FOR T H I S COLLECTION OF INFORMATION I S E S T I M A T E D TO VARY FROM TEN TO TWENTY M I N U T E S
W I T H AN AVERAGE OF 1 5 MINUTES PER RESPONSE, I N C L U D I N G T I M E FOR R E V I E W I N G INSTRUCTIONS, SEARCHING
E X I S T I N G DATA SOURCES, GATHERING AND M A I N T A I N I N G THE NECESSARY DATA, AND COMPLETING AND R E V I E W I N G
THE C O L L E C T I O N OF INFORMATION.
SEND COMMENTS REGARDING T H I S BURDEN E S T I M A T E OR ANY OTHER ASPECT
OF T H I S COLLECTION OF INFORMATION TO THE PROGRAM SUPPORT CENTER REPORTS CLEARANCE OFFICER,
PROGRAM SUPPORT CENTER, ROOM 17-AO%,.PARKLAWN B U I L D I N G , 5 6 0 0 F I S H E R S LANE, ROCKVILLE, MD. 2 0 8 5 7
'e

STANDARD FORM 2 7 0

x n

D O
T R I M

E X C E S S

N O T
T H I S
M A R G I N