Request for Extension

OMB Approved No. 1505-0271

Expiration Date: 11/30/2021

Coronavirus State and Local Fiscal Recovery Funds
Request for Extension Form (First 30-Day Extension for Distribution of Funds to Nonentitlement Units of Local Government)

The Coronavirus State and Local Fiscal Recovery Funds (SLFRF) Program, established by Sections 602 and 603 of the Social Security Act, as added by section 9901 of the American Rescue Plan Act of 2021 (ARPA), authorizes the U.S. Department of the Treasury (Treasury) to make payments to states for distribution to their nonentitlement units of local government (NEUs). Section 603(b)(2)(C)(i) of the Act states that “[n]ot later than 30 days after a State receives a payment,” the state “shall distribute” funds to each NEU in the state. Section 603(b)(2)(C)(ii)(I) directs Treasury to grant a 30-day extension if a state certifies an “excessive administrative burden” in writing before the end of the 30-day distribution period.

To request their first 30-day extension, states must complete the information below and return to Treasury by emailing or replying to [email protected] with the subject line “NEU Distribution - Extension Form” before the end of the 30-day distribution period. Treasury will grant all timely and complete requests for the first 30-day extension, as provided for in the statute.

Request for Extension

______________________ (Name of State) hereby certifies that it would constitute an excessive administrative burden to distribute SLFRF funding to one or more NEUs in its state within the 30-day distribution period as outlined in Section 603(b)(2)(C)(i), and requests, pursuant to Section 603(b)(2)(C)(ii)(I), an extension for an additional 30 days to distribute funding to its NEUs.

For purposes of determining the beginning of the 30-day distribution period outlined in Section 603(b)(2)(C)(i), the state acknowledges that Treasury will assume that the state receives its NEU payment under Section 603(b)(2)(B) three business days after the “invoice date,” which is the date on which Treasury initiates the payment to the state. This date can be found on Treasury’s website for the SLFRF program. This first extension will add 30 additional days to the initial 30-day distribution period for states to distribute funding to their NEUs.

As of the date of this request, the state has completed the following. Please check all that apply and fill in blanks where applicable.

☐ Determined the eligibility of and allocated funds to NEUs

☐ Begun accepting and processing requests for payment from NEUs

☐ Distributed payments to ____________ out of ___________ NEUs

I certify to the U.S. Department of the Treasury that the information provided above is true and correct.

___________________________________
Signature of Authorized Representative of the State Print Name: ____________________________
Title: __________________________________

Date: __________________________________

PAPERWORK REDUCTION ACT NOTICE

The information collected will be used for the U.S. Government to process requests for support. The estimated burden associated with this collection of information is 1 hour per response. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Office of Privacy, Transparency and Records, Department of the Treasury, 1500 Pennsylvania Ave., N.W., Washington, D.C. 20220. DO NOT send the form to this address. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid control number assigned by OMB.