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13. CERTIFICATION
<br />SIGNATURE OF AUTHORIZED CERTIFYING DATE REQUEST
<br />SUBMITTED
<br />I certify that to the best of my knowledge
<br />and belief the data on the reverse are
<br />May 27, 2011
<br />correct and that all outlays were made in
<br />accordance with the grant conditions or
<br />
<br />other agreement and that payment is due
<br />TYPED OR PRINTED NAME AND TITLE TELEPHONE (AREA CODE,
<br />and has not been previously requested.
<br />NUMBER, EXTENSION)
<br />Diane Steeck, Wetland Ecologist
<br />541.682.4927
<br />This space for agency use
<br />Public reporting burden for this collection of information is estimated to average 60 minutes
<br />per response, including time for reviewing instructions, searching existing data sources,
<br />gathering and maintaining the data needed, and completing and reviewing the collection of
<br />information. Send comments regarding the burden estimate or any other aspect of this
<br />collection of information, including suggestions for reducing the burden to the Office of
<br />Management and Budget, Paper Reduction Project (0348-0004), Washington DC 20503.
<br />PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT AND
<br />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, 11g, 11i, 12 and 13 are self-explanatory; specific instructions for other items are as follows:
<br />Item Entry Item Entry
<br />2Indicate whether request is prepared on cash or accrued programs, functions, or activities should be shown in the "total'
<br />expenditure basis. All requests for advances shall be prepared column on the first page.
<br />on a cash basis.
<br /> 11a Enter in "as of date," the month, day and year of the ending of the
<br />4Enter the Federal grant number, or other identifying number
<br />accounting period to which this amount applies. Enter program
<br />assigned by the Federal sponsoring agency. If the advance or
<br />reimbursement is for more than one grant or other agreement, outlays to date (net of refunds, rebates, and discounts), in the
<br />insert N/A; then, show the aggregate amounts. On a separate appropriate columns. For requests prepared on a cash basis,
<br />sheet, list each grant or agreement number and the Federal outlays are the sum of actual cash disbursements for goods and
<br />share of outlays made against the grant or agreement. services, the amount of indirect expenses charged, the value of in-
<br />kind contributions applied, and the amount of cash advances and
<br />6Enter the employer identification number assigned by the U.S.
<br />payments made to subcontractors and subrecipients. For
<br />Internal Revenue Service, or the FICE (institution) code if
<br />requests prepared on an accrued expenditure basis, outlays are
<br />requested by the Federal agency.
<br />the sum of the actual cash disbursements, the amount of indirect
<br />7This space is reserved for an account number or other
<br />expenses incurred, and the net increase (or decrease) in the
<br />identifying number that may be assigned by the recipient.
<br />amounts owed by the recipient for goods and other property
<br />received and for services performed by employees, contracts,
<br />8Enter the month, day, and year for the beginning and ending of
<br />subgrantees and other payees.
<br />the period covered in this request. If the request is for an
<br />advance or for both an advanced and reimbursement, show the
<br />period that the advance will cover. If the request is for
<br />reimbursement, show the period for which the reimbursement
<br />covers.
<br />NotThe Federal sponsoring agencies have the option of requiring 11b Enter the cumulative cash income received to date, if requests are
<br />e:recipients to complete items 11 or 12, but not both. Item 12 prepared on a cash basis. For requests prepared on an accrued
<br />should be used when only a minimum amount of information is expenditure basis, enter the cumulative income earned to date.
<br />needed to make an advance and outlay information contained Under either basis, enter only the amount applicable to program
<br />in item 11 can be obtained in a timely manner from other income that was required to be used for the project or program by
<br />reports. the terms of the grant or other agreement.
<br />11The purpose of the vertical columns (a), (b), and (c), is to 11d Only when making request for advance payments, enter the total
<br />provide space for separate cost breakdowns when a project has estimated amount of cash outlays that will be made during the
<br />been planned and budgeted by program, function, or activity. If period covered by the advance.
<br />additional columns are needed, use as many additional forms
<br />as needed and indicate page number in space provided in
<br />upper right; however, the summary totals of all
<br /> 13
<br />Complete the certification before submitting this request.
<br />STANDARD FORM 270 (Rev. 7-97) Back
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