Request for Advance or Reimbursement

OMB APPROVAL NO.

ADVANCE

PAYMENT

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

PAGES

a. "X" one or both boxes
1.

2. BASIS OF REQUEST

REIMBURSE-

CASH

MENT

TYPE OF

(See instructions on back)

OF

0348-0004

REQUEST FOR ADVANCE
OR REIMBURSEMENT

PAGE

b. "X" the applicable box

REQUESTED

FINAL

ACCRUAL

PARTIAL

4. FEDERAL GRANT OR OTHER

5. PARTIAL PAYMENT REQUEST

IDENTIFYING NUMBER ASSIGNED

NUMBER FOR THIS REQUEST

BY FEDERAL AGENCY

6. EMPLOYER IDENTIFICATION

7. RECIPIENT'S ACCOUNT NUMBER

NUMBER

OR IDENTIFYING NUMBER

8.

PERIOD COVERED BY THIS REQUEST

FROM (month, day, year)

TO (month, day, year)

9. RECIPIENT ORGANIZATION

10. PAYEE (Where check is to be sent if different than item 9)

Name:

Name:

Number

Number

and Street:

and Street:

City, State

City, State

and ZIP Code:

and ZIP Code:

COMPUTATION OF AMOUNT OF REIMBURSEMENTS/ADVANCES REQUESTED

11.

(a)

(b)

(c)

PROGRAMS/FUNCTIONS/ACTIVITIES

a. Total program

(As of date)

outlays to date

TOTAL
$

$

$

$

0.00

b. Less: Cumulative program income
c. Net program outlays (Line a minus
line b)

0.00

0.00

0.00

0.00

d. Estimated net cash outlays for advance

0.00

period

0.00

e. Total (Sum of lines c & d)

0.00

0.00

0.00

0.00

f. Non-Federal share of amount on line e

0.00

g. Federal share of amount on line e

0.00

h. Federal payments previously requested

0.00

i. Federal share now requested (Line g
minus line h)
j.

Advances required by
month, when requested
by
Federal
grantor
agency for use in making
prescheduled advances

0.00

0.00

0.00

0.00

1st month

0.00

2nd month

0.00
0.00

3rd month
12.

ALTERNATE COMPUTATION FOR ADVANCES ONLY

a. Estimated Federal cash outlays that will be made during period covered by the advance

$

b. Less: Estimated balance of Federal cash on hand as of beginning of advance period
$

c. Amount requested (Line a minus line b)
AUTHORIZED FOR LOCAL REPRODUCTION

(Continued on Reverse)

0.00

STANDARD FORM 270 (Rev. 7-97)

Prescribed by OMB Circulars A-102 and A-110

CERTIFICATION

13.

SIGNATURE OR AUTHORIZED CERTIFYING OFFICIAL

I

certify

that

to

the

best

of

DATE REQUEST

my

SUBMITTED

knowledge and belief the data on the

January 30, 2014

reverse are correct and that all outlays
were

made

in

accordance

grant conditions

or

other

with

the

TYPED OR PRINTED NAME AND TITLE

TELEPHONE (AREA

agreement

CODE, NUMBER,
EXTENSION)

and that payment is due and has not
been previously requested.

This space for agency use

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.

INSTRUCTIONS
Please type or print legibly. Items 1, 3, 5, 9, 10, 11e, 11f, 11g, 11i, 12 and 13 are self-explanatory; specific
instructions for other items are as follows:
Item

Entry

Item

2 Indicate whether request is prepared on cash or accrued
expenditure

basis.

All

requests

for

advances

shall

Entry

activity. If additional columns are needed, use as many

be

additional forms as needed and indicate page number in

prepared on a cash basis.

space provided in upper right; however, the summary
totals of all programs, functions, or activities should be

4 Enter

the

Federal

grant

number,

or

other

identifying

shown in the "total" column on the first page.

number assigned by the Federal sponsoring agency. If
the advance or reimbursement is for more than one grant

11a

Enter in "as of date," the month, day, and year of the

or other agreement, insert N/A; then, show the aggregate

ending of the accounting period to which this amount

amounts.

or

applies. Enter program outlays to date (net of refunds,

outlays

rebates, and discounts), in the appropriate columns. For

On

agreement

a

separate

number

and

sheet,

the

list

Federal

each

share

grant
of

made against the grant or agreement.

requests prepared on a cash basis, outlays are the sum
of actual cash disbursements for goods and services,

6 Enter the employer identification number assigned by the

the amount of indirect expenses charged, the value of in-

U.S. Internal Revenue Service, or the FICE (institution)

kind

code if requested by the Federal agency.

advances and payments made to subcontractors and

contributions

subrecipients.
7 This space is reserved for an account number or other

For

applied,

requests

and

the

amount

prepared

on

an

expenditure basis, outlays are the sum of

identifying number that may be assigned by the recipient.

of

cash

accrued

the

actual

cash disbursements, the amount of indirect expenses
incurred,

and

amounts

owed

ending of the period covered in this request. If the request

property

received

is

employees, contracts, subgrantees and other payees.

8 Enter the month, day, and year for the beginning and

for

an

advance

or

for

both

an

advance

reimbursement, show the period that the
cover.

If

the

request

is

for

and

advance

reimbursement,

show

the

the

11b

sponsoring

agencies

decrease)

for

goods

and

for

services

in

and

the

other

performed

by

requests are prepared on a cash basis. For requests
expenditure

basis,

enter

the

requiring recipients to complete items 11 or 12, but not

enter only the amount applicable to program income that

both. Item 12 should be

was required to be used for the project or program by

only

option

accrued

cumulative income earned to date. Under either basis,

when

the

(or

recipient

of

used

have

increase

Enter the cumulative cash income received to date, if

prepared on an
Federal

the

will

period for which the reimbursement is requested.

Note: The

net

by

a

minimum

amount of information is needed to make an advance and

the terms of the grant or other agreement.

outlay information contained in item 11 can be obtained in
a timely manner from other reports.

11d

Only

when

making

requests

for

advance

payments,

enter the total estimated amount of cash outlays that will
11 The purpose of the vertical columns (a), (b), and (c) is to
provide
project

space
has

for

been

separate
planned

cost

and

breakdowns

budgeted

by

when

be made during the period covered by the advance.

a

program,

13

Complete the certification before submitting this request.

function, or
STANDARD FORM 270 (Rev. 7-97) Back