3135-0112 Individual Payment Request Form

OMB #: 3135-0112 Expires 11/30/16

National Endowment for the Arts

PAYMENT REQUEST FORM FOR GRANTS TO INDIVIDUALS
All Years
For payment, fill out and email this form to [email protected], or fax it to (202) 682-5609/5610. If you need assistance email
the Grants & Contracts Office at the same address or call (202) 682-5403. You can track receipt and processing of the
payment request at www.arts.gov/mygrant.

1. Name:

Last

2. Permanent Address:

First

Middle Initial

3. Grant #:.

4. E-Mail Address:

5. Request for Payment:

6. Reminders:
a. Funds are remitted via an Automated Clearing House
Payment (ACH). Complete Box 9 below with your bank
information. This data must be provided on every payment
request you submit. Incorrect account numbers will
prevent your bank from crediting your account.

a. Grant Amount

$

b. Amount previously requested

$

b. Labor Assurances. By signing below, you are also certifying
to the Assurances as to Labor Standards on page 2 of this
form.

c. Amount now requested.

$

c. Progress report. Complete Box 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.

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
9. FOR ACH TRANSFER OF FUNDS:

Telephone Number
Date
• For Agency Use Only:
Reviewed by:_____________________________

Name of Bank:
City/State:
RTN #:
Bank Account #:
Checking
Social Security Number: * * *- * *-

Initials/Date

Approved by:_____________________________
Name/Date

Savings
Rev. 9/25/13

Payment Request Form for Grants to Individuals
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