3135-0112 Individual Payment Request Form

OMB #: 3135-0112 Expires 11/30/10

NATIONAL ENDOWMENT FOR THE ARTS

PAYMENT REQUEST FORM FOR GRANTS TO INDIVIDUALS
[ For All Grant Years ]
Please fill out online, type, or print clearly. Complete, sign, 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.

1. Name:

2. Permanent Address:

Last,
3. Grant #:

First,

Middle Initial

--

--

5. Request for Payment:

6. Reminders:
a. Funds can only be remitted via Electronic Funds Transfer. You
must complete #9 below for an Automated Clearing House (ACH)
payment to your bank. This information must be provided on every
payment request you submit. NOTE: Incorrect numbers will
prevent your bank from crediting your account.

a. Grant Amount............. $

b. Amount previously
requested ................... $

c.

4. E-Mail Address:

.

b. Labor Assurances. By signing below, grantee is also certifying to
the Assurances as to Labor Standards on page 2 of this form.
c. Progress report. Complete #7 the first time the cumulative
amount requested exceeds two-thirds of the grant amount.
Consult the Reporting Requirements document included in your
grant award package for guidance.

Amount now
requested ................... $

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

8. To the best of my knowledge and belief, the above information is correct and all expenditures will be made in
accordance with the purposes of the award and the “General Terms and Conditions for Grants to Individuals.”
X
Signature

(
)
-Telephone Number
•

9. For ACH transfer of funds:

Date

For Agency use only:

Name of Bank
Reviewed by

City/State
--

RTN #

--

Initials/Date

.
Approved by

Bank Account #
checking
Social Security Number:

Name/Date

savings
--

--

.

Request For Advance or Reimbursement
Page 2

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