3135-0112 Individuals Payment Request Form (FY18 and Earlier)

OMB #: 3135-0112 Expires: TBD

National Endowment for the Arts

PAYMENT REQUEST FORM FOR GRANTS TO INDIVIDUALS
For Awards made before October 1, 2018
For payment, fill out and email this form to [email protected]. If you need assistance email the Grants & Contracts Office
at the same address or call (202) 682-5403.

1. Name:

Last

2. Permanent Address:

First

Middle Initial

3. Grant #:

4. Email 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: * * *- * *Rev. 1/28/19

Initials/Date

Approved by:_____________________________
Name/Date

Savings

• Finance, Use this Date:

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
Privacy Act
The following notice is furnished in accordance with the Privacy Act of 1974, 5 U.S.C. 552a:
This information is solicited under the authority of the National Foundation on the Arts and the Humanities
Act, 20 U.S.C. 951 et seq. and is used for the purpose of grant awards. Personal data including home address
and home telephone number will not be released and is exempt from disclosure under FOIA exemption (b)
(6). Failure to provide the requested information could result in rejection of your application.
Paperwork Reduction Act Statement
The public reporting burden for this collection of information is estimated at an average of one hour per
response. This includes the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. We welcome any
suggestions that you might have on improving the guidelines and making them as easy to use as possible.
Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to: [email protected], attention: Reporting Burden. Note: Applicants are
not required to respond to the collection of information unless it displays a currently valid U.S. Office of
Management and Budget (OMB) control number.