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JUL-24-00 MON 03.56 PM US EPA MD FAX N0, 206553495? P. 02/02
<br /> ' CER71FiCAT10N
<br /> 13• .n~~ Oi~IGAI DATc R~pUEST
<br /> SIGNPAtRE OR-4 SD C _ 9KAI
<br /> ~ ~Y that t0 the best ~ my ~ '
<br /> knoinAedge and Belief the ttata on thw 8 / 4 / 01
<br /> reverse a~ correct and that all outlays ,
<br /> ~ made in accordance with the ' TYVED ne PRI TIRE TcL_PNONE (AaEA
<br /> PEGGY HAMLIN r'ODe'"uaceE.R' •
<br /> grant wnditioris or other agreement °~'4NI 541 682 5834
<br /> amd that payment is due and has not FINANCIAL •ANALYS-f AIC -
<br /> been previously requested.
<br /> This space for agency use ~ -
<br /> Public repotting Darden for this co1lQGtion of information iS estimated to average 60 minutes per
<br /> response. including time fot reviewing instructions, searching ~~9 d~•~~• gathering and
<br /> meittta,ning the data needed, and compietin9 and reviewing the mllaction of information. Send
<br /> commemts regarding the balder estimate a' arty other of this collec5on of information,
<br /> • including suggestions for reducing this burden. to the Office of Nlanagerrtent and Budget, Paperwork
<br /> Reduction Project (03Rt3.0004), Washington. OC 205113.
<br /> PLEASE DO NOT RETURN YOUR COMPLETEt) FORM TO THE OFFICE OF MANAGEMENT
<br /> • AND BUDGEr. SEND i7 TO TI'IE ADDKtESS PROVIDED BY THE SPONSOF2ING AGENCY.
<br /> - INSTRUCI'tONS
<br /> please type or print legibly. Items 1, 3, 5, 9, 10, 11a, 11f, 11g, 11i, i2 and 73 are self-explanatory; speci~ic
<br />
<br /> { instructions for other items are as follows:
<br /> ErthSi I(etn ~rttry -
<br /> ltem _ .
<br /> Z Indicate whether request is prepared on cash or accrued activity. If additional columns are needed, use as many
<br /> ests for advances shall be additional farms as needed and indicate page number in
<br /> basis. All r u
<br /> d~ture
<br /> expert t eq
<br /> s ace rovided in u er right; riowever, the summary
<br /> prepared on a cash bans. P P PP
<br /> totals of all programs, functions, or activities should be
<br /> -
<br /> - - -
<br /> 4 Enter the Federal grant . number, or ether identifying _ shown In the"total" cotramn-on the ~ rs -page. • _
<br /> -
<br /> --------~----number assii~ned-by-the-~ederal--sponsoriny agency. If
<br /> the advance or reimbursement is for more than one' grant 11a t:'rter in "as of date," the month, day, and year of the ,
<br /> or-other agreement, insert NIA; then, show the°aggragate ending of the accounting period to which.,-this amount
<br /> amounts. C7n 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 /> ~gairtst~he-grar+t-or-agreemen#, regyests~epared on a cash basis outlays are the sum
<br /> of actual cash disbursements for goods .and services,
<br /> 6 Enter the employer identfication number assignEd by the the amount of indirect expenses charged, he value-of in-
<br /> ~ _ U. S. internal Revenue Service, or the F1GE (institution) kind contributions applied, and the amount of cash
<br /> coda If requested by the
<br /> Federal agency. ~ advances and payments made to~-subcontre~ctar5 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 /> --iden#ifying number that-may-be assigned.by.-the recipient. cash disbursements, the amount of indirect expenses
<br /> _ n~-reasa~-er-=deer _ -
<br /> 'T~tt~'ed,-and-=th ea°~-'=
<br /> the
<br /> 8Enter' 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 Ifthe request.... property received and for services performed by
<br /> is for an advance or fur 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 agenries have the option of cumulative income earned to date. Under either basis,
<br /> requiring recipients to complete items 1 ~ or 12, but not enter only the amount applicable tv program income that
<br /> both. {rem 12 should be used when only a minimum • was required to be used for the project or program by
<br /> amount of information is needed to make an advance and the terms of the grant or other agreement.
<br /> outlay informafion •contained in item 11 can be obtained in
<br /> a timely manner from other reports. 11d Only when making requests fur advance payments,
<br /> enter the total estimated atr•.ount of cash outlays that will
<br /> 11 The purpose of the veRical columns (a), (b), and (c) is to be made during the period Covered 5y the atlvance.
<br /> provide space for separate cost breakdowns when a
<br /> project has bean planned and budgeted by program. 13 Complete the certification before submit?_ing this request.
<br /> ' fUnCtlOn, or STANDPRO fGRM.T)P (Rd. T•8'7) astck
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