Request for Advance or Reimbursement

OMB Number: 4040-0012
Expiration Date: 02/28/2022
a. "X" one or both boxes

REQUEST FOR ADVANCE
OR REIMBURSEMENT

1.
TYPE OF
PAYMENT
REQUESTED

ADVANCE
REIMBURSEMENT
b. "X" the applicable box

2. BASIS OF REQUEST
CASH
ACCRUAL

FINAL
PARTIAL

3. FEDERAL SPONSORING AGENCY AND ORGANIZATIONAL
ELEMENT TO WHICH THIS REPORT IS SUBMITTED

5. PARTIAL PAYMENT REQUEST
NUMBER FOR THIS REQUEST

8.

6. EMPLOYER IDENTIFICATION
NUMBER

PERIOD COVERED BY THIS REQUEST

From:

To:

9. RECIPIENT ORGANIZATION
Name:
Street1:
Street2:
City:
County:
State:
Province:
Country:
ZIP / Postal Code:
10. PAYEE (Where check is to be sent if different than item 9)
Name:
Street1:
Street2:
City:
County:
State:
Province:
Country:
ZIP / Postal Code:

4. FEDERAL GRANT OR OTHER IDENTIFYING NUMBER
ASSIGNED BY FEDERAL AGENCY

7. FINANCIAL ASSISTANCE
IDENTIFICATION NUMBER

11.

COMPUTATION OF AMOUNT OF REIMBURSEMENTS/ADVANCES REQUESTED

PROGRAMS/FUNCTIONS/
ACTIVITIES

(a)

(b)

(c)
TOTAL

a. Total program
outlays to date

(As of date)
$

$

$

$

b. Less: Cumulative program
income

0.00

c. Net program outlays (Line a
minus line b)
d. Estimated net cash outlays for
advance period

0.00

0.00

0.00

0.00
0.00

e. Total (Sum of lines c & d)

0.00

0.00

0.00

0.00

f. Non-Federal share of amount
on line e
g. Federal share of amount on
line e

0.00
0.00

h. Federal payments previously
requested

0.00

i. Federal share now requested
(Line g minus line h)
j. Advances required
by month, when
requested by Federal
grantor agency for
use in making
prescheduled
advances

12.

0.00

0.00

0.00

0.00

0.00

1st month

0.00

2nd month

0.00

3rd month

0.00

ALTERNATE COMPUTATION FOR ADVANCES ONLY
$

a. Estimated Federal cash outlays that will be made during period covered by the advance
b. Less: Estimated balance of Federal cash on hand as of beginning of advance period

$

c. Amount requested (Line a minus line b)
13.

0.00

CERTIFICATION

I certify that to the best of my knowledge and belief the data on the reverse 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.
SIGNATURE OR AUTHORIZED CERTIFYING OFFICIAL

DATE REQUEST SUBMITTED

TYPED OR PRINTED NAME AND TITLE
Prefix:

First Name:

Last Name:

Middle Name:
Suffix:

Title:
TELEPHONE (AREA CODE, NUMBER, EXTENSION)

This space for agency use

Public reporting burden for this collection of information is estimated to average 60 minutes per response, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the
Office of Management and Budget, Paperwork Reduction Project (0348-0004), Washington, DC 20503.
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND BUDGET. SEND IT TO THE ADDRESS
PROVIDED BY THE SPONSORING AGENCY.

INSTRUCTIONS
Please type or print legibly. Items 1, 3, 5, 9, 10, 11e, 11f, 11g, 11i, 12 and 13 are self-explanatory; specific instructions
for other items are as follows:
Item

Entry

2 Indicate whether request is prepared on cash or accrued
expenditure basis. All requests for advances shall be
prepared on a cash basis.
4 Enter the Federal grant number, or other identifying number
assigned by the Federal sponsoring agency. If the advance
or reimbursement is for more than one grant or other
agreement, insert N/A; then, show the aggregate amounts.
On a separate sheet, list each grant or agreement number
and the Federal share of outlays made against the grant or
agreement.
6 Enter the employer identification number assigned by the
U.S. Internal Revenue Service, or the FICE (institution)
code if requested by the Federal agency.
7 This space is reserved for an account number or other
identifying number that may be assigned by the recipient.
8 Enter the month, day, and year for the beginning and
ending of the period covered in this request. If the request
is for an advance or for both an advance and
reimbursement, show the period that the advance will
cover. If the request is for reimbursement, show the period
for which the reimbursement is requested.
Note: The Federal sponsoring agencies have the option of
requiring recipients to complete items 11 or 12, but not
both. Item 12 should be used when only a minimum
amount of information is needed to make an advance
and outlay information contained in item 11 can be
obtained in a timely manner from other reports.
11 The purpose of the vertical columns (a), (b), and (c) is to
provide space for separate cost breakdowns when a
project has been planned and budgeted by program,
function, or activity. If additional columns are needed, use

Item

Entry

as many additional forms as needed and indicate page
number in space provided in upper right; however, the
summary totals of all programs, functions, or activities
should be shown in the "total" column on the first page.
11a Enter in "as of date," the month, day, and year of the
ending of the accounting period to which this amount
applies. Enter program outlays to date (net of refunds,
rebates, and discounts), in the appropriate columns. For
requests prepared on a cash basis, outlays are the sum
of actual cash disbursements for goods and services,
the amount of indirect expenses charged, the value of
in- kind contributions applied, and the amount of cash
advances and payments made to subcontractors and
subrecipients. For requests prepared on an accrued
expenditure basis, outlays are the sum of the actual
cash disbursements, the amount of indirect expenses
incurred, and the net increase (or decrease) in the
amounts owed by the recipient for goods and other
property received and for services performed by
employees, contracts, subgrantees and other payees.
11b Enter the cumulative cash income received to date, if
requests are prepared on a cash basis. For requests
prepared on an accrued expenditure basis, enter the
cumulative income earned to date. Under either basis,
enter only the amount applicable to program income
that was required to be used for the project or program
by the terms of the grant or other agreement.
11d Only when making requests for advance payments,
enter the total estimated amount of cash outlays that
will be made during the period covered by the advance.
13 Complete the certification before submitting this request.