190-F-04-001 EPA Payment Request

United States
ENVIRONMENTAL PROTECTION AGENCY

U.S. EPA PAYMENT REQUEST

OMB Control No. 2030-0020
Approval expires MM/DD/YYYY

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2030-0020). Responses to this collection of information are required to obtain an assistance agreement
(40 CFR Part 30, 40 CFR Part 31, and 40 CFR Part 33 for awards made prior to December 26, 2014, and 2 CFR 200, 2 CFR 1500, and 40 CFR Part 33 for awards made after December 26, 2014). An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be
0.5 hours per response. Send comments on the Agency’s need for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to the Regulatory Support Division
Director, U.S. Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.

Recipient Name:

Contact Person:
Phone #:
Email address:

Fax #:
EFT #

Request #

Assistance Agreement

Account No/Activity Code
(Superfund Site Specific)

Cash on Hand: $

$ Amount

Mark
(X) if
Credit

For EPA Internal Use Only

TOTAL AMOUNT REQUESTED $
I certify that to the best of my knowledge and belief the data above are correct and that all outlays were made in accordance with the grant conditions or other
agreement and that payment is due and has not been previously requested.
APPROVALS:

Recipient Approving Official’s Signature

EPA Certifying Officer Approval
EPA 190-F-04-001

Date Approved
Date Approved

$ EPA APPROVED AMOUNT
For EPA Use Only