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<br /> t3. CERTIFICATION
<br /> 31GNATURE OR AUTHORIZED CERTIFYING OFFICIAL DATE REQUEST
<br /> I certify that to the best of my sueMlrrEo
<br /> knowledge and belief the data on the
<br /> reverse are correct and that all outlays October 20, 2003
<br /> were made in accordance with the -IypED OR P INTER NAME AND TrfGE TELEPHONE (AREA
<br /> grant conditions or other agreement CODE, NUMBER,
<br /> j and that payment is due and has not Kurt Corey, Public Works 'I ctor, City of Eugene ExTENS1oN~
<br /> been previously requested. (541) 682-5241
<br /> This space for agency use
<br /> ' Public reporting burden for this collection of information is estimated to average 60. minutes per
<br /> response, including time for reviewing instructions, searching existing data sources, gathering and
<br /> maintaining the data needed, and completing and reviewing the collection of information. Send
<br /> comments regarding the burden estimate or any other aspect of this collection of information,
<br /> including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork
<br /> Reduction Project (0348-0004), Washington, DC 20503.
<br />
<br /> I
<br /> PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT
<br /> AND BUDGET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
<br /> INSTRUCTIONS
<br /> Please type or print legibly. Items 1, 3, 5, 9, 10, 11e, 11f, 1'I g, 11i, 12 and 13 are self-explanatory; specific
<br /> instructions for other items are as follows:
<br /> Item Entry Item Entry
<br /> 2 Indicate whether request is prepared on cash or accrued activity. If additional columns are needed, use as many
<br /> expenditure basis. All requests for advances shall be additional forms as needed and indicate page number in
<br /> prepared on a cash basis. spade provided in upper right; however, the summary
<br /> totals of all programs, functions, or activities should be
<br /> 4 Enter the ,Federal grant number, or other identifying shown in the "total" column on the first page.
<br /> number assigned by the Federal sponsoring agency. If
<br /> the advance oFreimbursement is for more than one rant
<br /> g 11a Enter in "as of date," the month, day, and year of the
<br /> or other agreement, insert N/PA; then, show the aggregate ending of the accounting period to which this amount
<br /> amounts. Or a separate sheet, list each grant or applies. Enter program outlays to date (net of refunds,
<br /> agreement number and the Federal share of outlays rebates, and discounts), in the appropriate columns. For
<br /> made against the grant or agreement. requests prepared on a cash basis, outlays are the sum
<br /> of actual cash disbursements .for goods and services, -
<br /> 6 Enter the employer identification number assigned by the the amount of indirect expenses charged, the value of in-
<br /> U.S. lntemal Revenue Service, or the FIGS (institution) kind contributions applied, and the amount of cash
<br /> code if requested by the Federal agency. advances and payments made to subcontractors and
<br /> subrecipients. For requests prepared on an accrued
<br /> 7 This space is reserved for an account number or other expenditure basis, outlays are the sum of the actual
<br /> identifying number that may be assigned by the recipient. cash disbursements, the amount of indirect expenses
<br /> incurred, and the net increase (or decrease) in the
<br /> 8_ Ent~r_the month, day,_ and year_ for--the beginning .and =amounts- owed°°by the=recipient for-=goods=and other.- -
<br /> ending of the period covered in this request. If the request property received and for services performed by
<br /> is for an advance or for both an advance and employees, contracts, subgrantees and other payees.
<br /> reimbursement, show the period that the advance will
<br /> .cover. If the request is for reimbursement, show the 11b Enter the cumulative cash income received to date, if
<br /> period for which the reimbursement is requested. requests are prepared on a cash basis. For requests
<br /> prepared on an accrued expenditure basis, enter the
<br /> Note: The Federal sponsoring agencies have the option of cumulative income earned to date. Under either basis,
<br /> requiring recipients to complete items 11 or 12, but not enter only the amount applicable to program income that
<br /> both. Item 12 should be used when only a minimum was required. to be .used for. the project or _program by
<br /> amount ofinformation is needed to make an advance and the terms of the grant or other agreement.
<br /> outlay information contained in item 11 can be obtained in
<br /> a #imely manner from other reports. 11d Only when making requests fior advance -payments,
<br /> enter the total estimated amount of cash outlays that will
<br /> 11 The purpose of the vertical columns (a), (b), and (c) is to be made during the period covered by the advance.
<br /> provide space for separate cost breakdowns when a
<br /> project has been planned and budgeted by program, 13 Complete the certification before submitting'this request.
<br /> function, or
<br /> STANDARD FORM 270 (Rev. 7-97) Back
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