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OMB Control No. 0551-0046

CASH ADVANCE OR REIMBURSEMENT REQUEST

(FOR ALL PROGRAMS)

TO: Attn: Faye Johnson

US Department of Agriculture – Rm. 4159-S

1400 Independence Avenue, SW, Mail Stop 1034

Washington, DC 20250-1034

FROM: (Your Name)- Must be a person with signing authority

(Your Organization)

(Your Street Address)

(Your City, State and Zip code)

SUBJECT: Agreement Number: __________________, Budget Number: _________

COUNTRY: _______________________

In accordance with the above referenced Agreement and Budget, we hereby request the advance/reimbursement of $___________. These calculations are based on the table below wherein funds requested for administrative costs are indicated by "admin," funds for internal transportation, storage and handling, are indicated by "ITSH," and funds for activities that enhance the effectiveness of the program are indicated by "Projects."

* Please see Part II, Item II, Paragraph C of agreement for these figures. Double click table to insert information.

Please omit banking information.

Please be sure that all required financial reports have been submitted to FAD prior to requesting cash. Reports may be submitted by email along with the cash request (advance/reimbursement) if reporting is not up to date.

I hereby certify that the above information is correct and in accordance with the approved Program operating Budget and that the bank account listed above is this organization's account. I understand that any funds advanced must be obligated within 180 days as stated in the pertinent regulations (7 CFR 1499.6 for Food for Progress and 7 CFR 3019.22 for Local Regional Procurement and 7 CFR 1599.6 for McGovern-Dole).

By: ___________________________ Title: ________________________ Date: _____________________

----(USDA APPROVAL BELOW—THIS IS A ONE PAGE DOCUMENT)---

Concurrence:

FAD Analyst ________________________________ Date: ___________________

FAD Branch Chief ________________________________ Date: ___________________

FAD Director or Designee __________________________ ______ Date: ___________________