3135-0112 Payment Request Form

• OMB #: 3135-0112 Expires 11/30/10
• Please type or print clearly.
• Complete and fax this page to the Grants & Contracts Office:
202/682-5610 or 5609.
• If you need assistance, call 202/682-5403.
• Track receipt & processing of your payment request form online
at www.arts.gov/mygrant.

Request for Advance
or Reimbursement
(Payment Request Form)

2. Grant #:

1. National Endowment for the Arts
3. Type of payment requested:
Advance
b.
a.
Reimbursement

--

--

4. Basis of request:
Cash
Accrued Expenditures

Final
Partial

6. Taxpayer Identification Number (also known as
Employer Identification Number):
-_

7.

8. Grantee (Official IRS name/mailing address)

•

_

5. Payment Request #:

Period covered by this request (month/day/year):
From:

/

/

To:

/

/

Payment
Funds can only be remitted via Electronic Funds Transfer. You
must complete #12 below for an Automated Clearing House
(ACH) payment to your bank. This information must be
provided on every payment request you submit. Incorrect
numbers will prevent your bank from crediting your account.

•

9. Computation of amount requested:
a. Total project outlays to date
/
/ ) ................ $
(As of
b. Estimated net cash outlays
needed for 30-day advance ..
c. Total (a plus b) ......................
d. Non-Endowment share of
amount on line c ...................
e. Endowment share of amount
on line c (c minus d)..............
f. Endowment payments
previously requested.............
g. Endowment share now
requested (e minus f)............

Reminders

a. Authorizing Official. An authorizing official who either
signed the original application or has a signature
authorization on file must sign this form. If necessary,
submit an updated signature authorization form or letter.
b. Labor Assurances. By signing below, grantee is also
certifying to the Assurances as to Labor Standards (page 2).
c. Progress report. Complete #10 the first time the
cumulative amount requested exceeds two-thirds of the
grant amount. See the Reporting Requirements.

$

10. Progress report. Please respond in the space provided or attach to this form. Do NOT submit under separate cover.

11. Authorizing Official. To the best of my knowledge and belief, the data reported above are correct and all outlays
were made in accordance with grant conditions. Payment is due and has not been previously requested.
Signature: X

Date:

Name/Title:

Phone:

(

)

-

ext.

Contact Person:

Phone:

(

)

-

ext.

Fax:

(

)

-

e-mail:

•

12. For ACH transfer of funds:
Name of Bank
City/State
RTN #

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--

_

For Agency use only:
Reviewed by
Initials/Date
Approved by
Name/Date

Bank Account #
checking

savings

Request for Advance or Reimbursement
Page 2
(Please read below but do not submit with Payment Request Form)

ASSURANCES AS TO LABOR STANDARDS
UNDER SECTION 5(m) AND SECTION 7(g) OF THE NATIONAL
FOUNDATION ON THE ARTS AND THE HUMANITIES ACT OF 1965,
AS AMENDED
In consideration of a grant made under section 5 or 7 of the National Foundation on the Arts and
the Humanities Act of 1965, as amended, and in order to satisfy the conditions expressed in
section 5(m) or section 7(g) of that act so as to be eligible to receive the grant funds, Grantee
does hereby make this contractually binding promise to the Secretary of Labor that:
(1)

all professional performers and related or supporting professional personnel (other than
laborers or mechanics with respect to whom labor standards are prescribed in subsections
5(n) and 7(j) of the act) employed on projects or productions which are financed in whole
or in part under such sections will be paid, without subsequent deduction or rebate on any
account, not less than the prevailing minimum compensation for persons employed on
similar activities; and

(2)

no part of any project or production which is financed in whole or in part under section 5 or
section 7 of the National Foundation on the Arts and the Humanities Act of 1965, as
amended, will be performed or engaged in under working conditions which are unsanitary
or hazardous or dangerous to the health and safety of the employee engaged in such
project or production, including particularly, no work which is prohibited for safety or
sanitary reasons by any of the contracts with labor organizations listed in 29 CFR 505.3
(a). Grantee further promises to keep the records and permit the inspections provided by
29 CFR 505.5(b). Receipt of a copy of 29 CFR Part 505 is hereby acknowledged. This
promise may be enforced by the Secretary through any appropriate action at law or in
equity in any court of competent jurisdiction.

U.S. Department of Labor
ESA-38
Rev. June 1988