3135-0112 Payment Request Form (FY17 and Earlier)

OMB #: 3135-0112 Expires TBD

Request for Advance
or Reimbursement

E-mail this form to the Grants Office at [email protected]; or via fax to
202/682-5610. If you need assistance, call 202/682-5403 or email
[email protected].

(Payment Request Form)
1. National Endowment for the Arts

2. Award #:

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)
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)

$

c. SAM.gov. You must have an active registration in SAM (the System
for Award Management) to receive payment.
d. Payment. Funds can only be remitted via Electronic Funds

0

$
$

0

$
$

0

Transfer as an Automated Clearing House (ACH) payment. The
NEA uses bank information from your entity's Sam.gov record.
NEA payments will be made to this bank account. If your bank
information changes, you must update it in SAM.gov before
requesting payment.

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.

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:
Verify that SAM.gov has your organization’s current
banking information. NEA payments will be made to
this bank account. If your bank information changes,
you must update it in SAM.gov before requesting
payment.



For Agency use only:
Reviewed by
Initials / Date
Approved by
Name / Date

• Finance, Use this Date:
Revised 4.9.18

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,
ASconsideration
AMENDED of a grant made under section 5 or 7 of the National Foundation on the Arts and
In
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

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.