3135-0112 Payment Request Form

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

Request for Advance
or Reimbursement

 E-mail this form to the Grants & Contracts Office at
[email protected]; or via fax to 202/682-5610.

(Payment Request Form)

 Track the status of your request online at www.arts.gov/mygrant.
 If you need additional assistance, call 202/682-5403.

1. National Endowment for the Arts

2. Grant #:

3. Type of payment requested:
a.
Advance
b.
Reimbursement

4. Basis of request:
Cash
Accrued Expenditures

Final
Partial

6. Taxpayer Identification Number: (or EIN)
–

–

–

.

5. Payment Request:
#

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

.



8. Grantee: (Official IRS name/mailing address)

/

/

To:

/

/

Reminders:
a. Authorizing Official. This form must be submitted by an
Authorizing Official.
b. Progress report. You must provide a progress report in
Section 10 when the cumulative amount requested exceeds
two-thirds of your grant amount.

9. Computation of amount requested:
a. Total project outlays to date
$
10. (As of
/
/ )
b. Estimated net cash outlays
$
needed for 30-day advance
c. Total (a plus b)

c. SAM.gov. You must have an active registration in SAM (the
System for Award Management) to receive payment.

$

d. Recipient 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)

0

d. Payment. Funds can only be remitted via Electronic Funds
Transfer. You must complete #12 below for an Automated
Clearing House (ACH) payment. This information must be
provided on every payment request; missing or incorrect
numbers will delay your request and/or prevent your bank
from crediting your account.

0

e. Labor Assurances. By submitting this request, you are also
certifying to the Assurances as to Labor Standards outlined on
page 2 of this form.

$
$
$
$

See the General Terms & Conditions and Reporting Requirements
for additional guidance.

0

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

11. Authorizing Official: By signing this report, I certify to the best of my knowledge and belief that the report is true, complete and
accurate, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and
conditions of the Federal award. [Certification continues on page two.]

Name:

Date:

Title:

Phone:

(

)

-

ext.

Contact Person:

Phone:

(

)

-

ext.

Contact E-mail:

Fax:

(

)

-



12. Bank Information: (REQUIRED)
Name of Bank

For Agency use only:
Reviewed by
Initials / Date

City/State
RTN #

–

–

.

Approved by
Name / Date

Bank Account #
checking

savings

Revised 11/12/14

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

AUTHORIZING OFFICIAL CERTIFICATION
By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and
accurate, and the expenditures, disbursements, and cash receipts are for the purposes and objectives set forth
in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fraudulent information,
or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false
statements, false claims or otherwise. (U.S. Code Title 18, Section 1001 and Title 31, Sections 3729-3730 and
3801-3812).

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