Transfers Form - Non-Entitlement Units of Local Governme

OMB Approved No. 1505-0271

Expiration Date: 11/30/2021

Coronavirus State and Local Fiscal Recovery Funds
Non-Entitlement Units of Local Government
First Tranche Transfer Form

Local Government Information: Name: DUNS Number: Taxpayer Identification Number: FAIN (if applicable):

State Information: Name: DUNS Number: Taxpayer Identification Number: FAIN (if applicable):

Section 603(b) of the Social Security Act (the Act), as added by section 9901 of the American Rescue Plan Act (ARPA), Pub. L. No. 117-2 (March 11, 2021), authorizes the Department of the Treasury (Treasury) to make payments from the Coronavirus Local Fiscal Recovery Fund (CLFRF) to states and territories for distribution to nonentitlement units of local government (NEUs).

Section 603(c)(4) of the Act permits NEUs to transfer funds received from the CLFRF to the State in which such recipient is located.

The following election applies only to the first tranche of the allocation designated for the NEU. Guidance for transfer elections for a second tranche will be made available in advance of the disbursement of those funds.

1. For an NEU that has not yet received or requested a first tranche CLFRF payment from their State – please complete questions below.

The NEU may elect to redirect a portion or the full amount of their CLFRF first tranche allocation to the State government, and as a result the amount of the tranche allocation they would have received will be reduced or eliminated.

How much of the tranche allocation should be redirected to the State?

	First Tranche Amount
Total First Tranche Allocation Amount
Amount of First Tranche Allocation to be Redirected to the State
Amount of First Tranche Allocation to be Paid to the Local Government

In order for this transfer to be reflected in Treasury’s records, this form must be completed, signed, and returned by the NEU to the State, and the State should upload the completed and signed form to Treasury as part of its submission of quarterly Project and Expenditure Reports. The amount of the transfer will need to be returned to Treasury and the amount will be re-issued from Treasury to the State. The State should not use or plan to use redirected funds until the amount of such funds has been re-issued from Treasury to the State.

Upon receipt of the form, Treasury will provide further guidance for completing the transfer via the email addresses provided below. Treasury will not be able to complete the transfer until the State has submitted its Coronavirus State Fiscal Recovery Fund (CSFRF) certification to Treasury as required by section 602(d) of the Act.

2. For an NEU that has received or requested a first tranche CLFRF payment from their State – please complete questions below.

The NEU may elect to transfer a portion or the full amount of their CLFRF first tranche allocation to the State government.

How much of the tranche allocation should be transferred to the State?

	First Tranche Amount
Total First Tranche Allocation Amount
Amount of First Tranche Allocation to be Transferred to the State
Amount of First Tranche Allocation Remaining with the Local Government

In order for this transfer to be reflected in Treasury’s records, this form must be completed, signed, and returned by the NEU to the State, and the State should upload the completed and signed form to Treasury as part of its submission of quarterly Project and Expenditure Reports. The amount of the transfer will need to be returned to the State and the State will return such funds to Treasury and the amount will be re-issued from Treasury to the State. The NEU may not transfer the amount directly to Treasury.

Upon receipt of the form, Treasury will provide further guidance for completing the transfer via the email addresses provided below. Treasury will not be able to complete the transfer until the State has submitted its Coronavirus State Fiscal Recovery Fund (CSFRF) certification to Treasury as required by section 602(d) of the Act.

Certification

The following representatives of the recipient local government and State hereby certify to Treasury that the information provided above is true and correct.

In addition, the authorized representative of the State represents that the State accepts the transfer from the local government such that the State will be responsible as the prime recipient for the use and reporting of any funds transferred by the local government. Such funds will be subject to the CSFRF Award Terms and Conditions previously accepted by the State in connection with its payment from the CSFRF.

_______________________________________ Signature of Authorized Representative of the Local Government Name: Title: Date: Email:

_______________________________________ Signature of Authorized Representative of the State Name: Title: Date: Email:

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.

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