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<br /> TEXAS DEPARTMENT OF HEAL TH <br /> REQUEST FOR ADVANCE Approved by Office of Management and PAGE OF <br /> Budget. No. BC\-RO183 PAGES <br /> eR-REIMBURSEMENT 1. a. 'X' one. or both boxes 2. BASIS OF REQUEST <br /> Type of 0 advance 0 Reimbursement 0 CASH <br /> Payment <br /> Requested b. 'X' the applicabie box 0 ACCRUAL <br /> (See instructions on back) 0 FINAL 0 PARTIAL <br /> 3. FEDERAL SPONORING AGENCY AND ORGANIZATIONAL ELEMENT TO WHICH THIS 4. FEDERAL GRANT OR OTHER 5. PARTIAL PAYMENT REQUEST NUMBER FOR <br /> REPORT IS SUBMITTED. IDENTIFYING NUMBER ASSIGNED THIS REQUEST <br /> BY FEDERAL AGENCY <br /> TDH-DIVISION OF ORAL HEALTH 7460022381A 98-01 N/A <br /> B. EMPLOYER IDENTIFICATION NUMBER 7. RECIPIENTS ACCOUNT NUMBER 8. PERIOD COVERED BY THIS REQUEST <br /> OR IDENTIFYING NUMBER FROM (month. day. year) TO (Month. day, year) <br /> 17460022381000 N/A <br /> 9. Recipient Organization 10. Payee (Where check is to be sent if different than item 9) <br /> Name: City of San Marcos Name: N/A <br /> Number Number <br /> and Street: 630 E. Hopkins and Street: <br /> City, State City, State <br /> and ZIP: San Marcos, Texas 78666 and ZIP: <br /> 11. COMPUTATION OF AMOUNT OF REIMBURSEMENTS/ADVANCES REQUESTED <br /> (a) (b) (c) <br /> PROGRAMS/FUNCTIONS/ACTIVITIES. Fluoridation N/A N/A Total <br /> a. Total program outlays to date $25,000 $25,000 <br /> b. Less: Cumulative program income <br /> c. Net program outlays (Line a minus line b) <br /> d. Estimated net cash outlays for advance period <br /> e. Total (Sum oflines c & d) <br /> f. Non-Federal share of amount on line e <br /> $25,000 $25,000 <br /> g. Federal share of amount on line e <br /> - 0 - - 0 - <br /> h. Federal payments previously requested <br /> i. Federal share now requested (Line 9 $25,000 $25,000 <br /> minus line h) <br /> j. Advances required by 1 st month <br /> month, when requested <br /> by Federal grantor agency 2nd month <br /> for use in making pre- <br /> scheduled advances <br /> 3rd month <br /> 12. N/A <br /> a. Estimated Federal cash outlays that will be made during period covered by the advance $ N/A <br /> b. Less: Estimated balance of Federal cash on hand as of beginning of advance period <br /> c. Amount requested (Line a minus line b) $ <br /> 13. CERTIFICATION <br /> DATE REQUEST SUBMITTED <br /> I certify that to the best of my knowledge 9-29-98 <br /> and belief the data above are correct <br /> and that all outlays were made in <br /> accordance with the grant conditions or LARRY D. GILLEYI CITY MANAGER <br /> other ag'ìieement and that payment is <br /> due and as not been previously <br /> requested. <br /> TELEPHONE <br /> This space for agency use <br /> 270-101 Exhibit 3 STANDARD FORM 270 (7.76) <br /> Prescribed by Office of Management and Budget <br /> CIRCULARS NO. A-102 AND A.110 <br />