Standard Form 271 Outlay Report and Request for Reimbursement for Construc

OUTLAY REPORT AND REQUEST FOR REIMBURSEMENT
FOR CONSTRUCTION PROGRAMS

OMB APPROVAL NO. 0348-0002

OF
PAGES

1. TYPE OF REQUEST

(See instructions on back)

2. BASIS OF REQUEST

FINAL

PARTIAL

4. FEDERAL GRANT OR OTHER

3. FEDERAL SPONSORING AGENCY AND ORGANIZATIONAL ELEMENT TO
WHICH THIS REPORT IS SUBMITTED

PAGE

ACCRUAL

CASH

5. PARTIAL PAYMENT REQUEST NO.

IDENTIFYING NUMBER
ASSIGNED BY FEDERAL AGENCY

6. EMPLOYER IDENTIFICATION

PERIOD COVERED BY THIS REQUEST

7. RECIPIENT'S ACCOUNT NUMBER

NUMBER

OR IDENTIFYING NUMBER

F R O M (Month, day, year)

T O (Month, day, year)

9. RECIPIENT ORGANIZATION

1 0 . PAYE E (Where check is to be sent if different than item 9)

Name:

Name:

No. and Street:

No. and Street:

City, State and
ZIP Code:

City, State and
ZIP Code:

11.

STATUS OF FUNDS
PROGRAMS
CLASSIFICATION

a. Administrative expense

--

FUNCTIONS

--

ACTIVITIES

(a)

(b)

(c)

$

$

$

TOTAL
$

0.00

b. Preliminary expense

0.00

c. Land, structures, right-of-way

0.00

d. Architectural engineering basic fees

0.00

e. Other architectural engineering fee

0.00

f. Project inspection fees

0.00

g. Land development

0.00
0.00

h. Relocation expense
i. Relocation payments to individuals
and businesses

0.00

j. Demolition and removal

0.00

k. Construction and project improvement cost

0.00

l. Equipment

0.00

m. Miscellaneous cost

0.00

0.00

0.00

n. Total cumulative to date(sum of lines a thru m)

0.00

0.00
0.00

o. Deductions for program income

0.00

p. Net cumulative to date (line n minus line o)

0.00

0.00

0.00

q. Federal share to date

0.00

r. Rehabilitation grants (100% reimbursement)

0.00
0.00

0.00

s. Total Federal share (sum of lines q and r)

0.00

0.00

0.00

t. Federal payments previously requested
u. Amount requested for reimbursement

$

$

$
%

v. Percentage of physical completion of project
12. CERTIFICATION

$

%

0.00

%

%

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

DATE REPORT SUBMITTED

TYPED OR PRINTED NAME AND TITLE

T E L E P H O N E (Area code, number,
and extension)

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

DATE SIGNED

TYPED OR PRINTED NAME AND TITLE

T E L E P H O N E (Area code, number,
and extension)

a. RECIPIENT
I certify that to the best of my knowledge and
belief the billed costs or disbursements are
in accordance with the terms of the project
and that the reimbursement represents the
Federal share due which has not been
previously requested and that a n inspection
has been performed and all work is in
accordance with the terms of the award.

AUTHORIZED FOR LOCAL REPRODUCTION
PREVIOUS EDITION USABLE
271-103

b. REPRESENTATIVE
CERTIFYING TO LINE 11V

STANDARD FORM 271 (Rev. 7-97)

Prescribed by OMB Circular A-102 and A-110

INSTRUCTIONS
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.

Please type or print legibly. Items 3, 4, 5, 8, 9, 10, 11s and 11v are self explanatory; specific instructions for other items are as
follows:
Item

Entry

1 Mark the appropriate box. If the request is final, the amounts
billed should represent the final cost of the project.
2 Show whether amounts are computed on an accrued
expenditure or cash disbursement basis.
6 Enter the Employer Identification Number (EIN) assigned
b y the U.S. Internal Revenue Service or F I C E (institution)
code if requested by the Federal agency.
7 This space is reserved for a n account number or other
identifying number that may be assigned by the recipient.
1 1 T h e purpose of vertical columns (a) through (c) is to
provide space for separate cost breakdowns when a large
project h a s been planned a n d budgeted b y program,
function or activity. If additional columns ar e needed, use
a s m a n y additional forms a s needed a n d indicate page
number in space provided in upper right; however, the
summary totals of all programs, functions, or activities
should b e shown in the "total" column o n the first page.
All amounts are reported on a cumulative basis.
1 1 a Enter amounts expended for such items a s travel, legal
fees, rental of vehicles a n d a n y other administrative
expenses. Include the amount of interest expense when
authorized b y program legislation. Also show the amount
of interest expense on a separate sheet.
11b Enter amounts pertaining to the work of locating a n d
designing, making surveys a n d maps, sinking test holes,
and all other work required prior to actual construction.
11c Enter all amounts directly associated with the acquisition
of land, existing structures and related right-of-way.
11d Enter basic fees for services of architectural engineers.
11e Enter other architectural engineering services. D o not
include any amounts shown on line d.
11f Enter inspection and audit fees of construction and related
programs.
11g Enter all amounts associated with the development of
land where the primary purpose of the grant is land
improvement. T h e amount pertaining to land development
normally associated with major construction should b e
excluded from this category and entered on line k.
11h Enter the dollar amounts used to provide relocation
advisory assistance a n d net costs of replacement housing
(last resort). D o not include amounts needed for
relocation administrative expenses; these amounts should
be included in amounts shown on line a.
11i Enter the amount of relocation payments m a d e b y the
recipient to displaced persons, farms, business concerns,
and nonprofit organizations.

Item

Entry

11j Enter gross salaries a n d wages of employees of the
recipient a n d payments to third party contractors directly
engaged in performing demolition or removal of
structures from developed land. All proceeds from the
sale of salvage or the removal of structures should b e
credited to this account; thereby reflecting net amounts if
required by the Federal agency.
11k Enter those amounts associated with the actual
construction of, addition to, or restoration of a facility.
Also, include in this category, the amounts for project
improvements such a s sewers, streets, landscaping, a n d
lighting.
11l Enter amounts for all equipment, both fixed a n d
movable, exclusive of equipment used for construction.
F o r example, permanently attached laboratory tables,
built-in audio visual systems, movable desks, chairs,
and laboratory equipment.
11m Enter the amounts of all items not specifically mentioned
above.
11n Enter the total cumulative amount to date which should
be the sum of lines a through m.
11o Enter the total amount of program income applied to the
grant or contract agreement except income included o n
line j. Identify o n a separate sheet of paper the sources
and types of the income.
11p Enter the net cumulative amount to date which should be
the amount shown on line n minus the amount on line o.
11q Enter the Federal share of the amount shown on line p.
11r Enter the amount of rehabilitation grant payments m a d e
to individuals when program legislation provides 100
percent payment by the Federal agency.
11t Enter the total amount of Federal payments previously
requested, if this form is used for requesting
reimbursement.
11u Enter the amount now being requested for
reimbursement. This amount should b e the difference
between the amounts shown o n lines s a n d t. If different,
explain on a separate sheet.
1 2 a T o b e completed b y the official recipient official who is
responsible for the operation of the program. T h e date
should b e the actual date the form is submitted to the
Federal agency.
12b T o b e completed b y the official representative who is
certifying to the percent of project completion a s
provided for in the terms of the grant or agreement.

STANDARD FORM 271 (Rev. 7-97) Back