NOTES/INSTRUCTIONS:
Basis of Request: Indicate whether request is prepared on cash or accrued expenditure basis.
Federal Assistance Identification Number: This space is reserved for an account number or other identifying number that may be assigned by the recipient.
Period Covered by this Request: Enter the month, day, and year for the beginning and ending of the period covered in this request.
Period Computation of Amount of Reimbursements Requested: Complete all fields in this section for each program, function or activity relevant to this disbursement request within the period identified. Please provide separate cost breakdowns for each program, function, or activity. To do so, click "Add Another Response".
Total Program Outlays to Date: Enter the "as of date," of the ending of the accounting period to which this amount applies. Enter program outlays to date (net of refunds, rebates, and discounts). 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 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.
Less Cumulative Program Income: 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.
After you click Submit, you will be prompted to certify this disbursement request with e-signature.