3135-0112 Payment Request Form (FY18 and Later)

OMB#. 3135-0112 Exp: TBD

Payment Request #
Award #
Institution (Primary)
Primary Point of Contact

Award Period
1. Recipient Account or ID Number
2. Type of Payment Requested

Partial or Final

3. Basis of request

Cash or Accrual

4. Period Covered by this Request Starting Date
5. Period Covered by this Request Ending Date
6. a. Total Program Outlays

$xx,xxx as of MM/DD/YYYY

b. Estimated Net Cash Outlays Needed for Advance Period
c. Total (a plus b)
d. Non-Federal share of amount on line c
e. Federal Share of Amount on line c (c minus d)
f. Payment Previously Requested
g. Federal Share Now Requested (e minus f)
Progress Report:

Progress Report Approved?
Submission Date
Staff Reviewer
Status/Date
Date Paid
Staff Comments:

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.