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INSTRUCTIONS Please type or printlegibly. Items 1, 3, 5,9,10, 11c, 11e, 111, 11g, 11i, 12 and 13 are self-explanatory; specific instructions for other items are as follows: Item Entry Item Entry 2 Indicates whether request is prepared on cash or Use as many additional forms as needed and indicate accrued expenditure basis. All requests for advances page number in space provided in upper right; shall be prepared on a cash basis. however, the summary totals of all programs functions, or activities should be shown in the "Total" column on 4 Enter the Federal grant number, or other identifying the first page. number assigned by the Federal sponsoring agency. If the advance or reimbursement is for more than one 11a Enter in "As of date", the month, day, and year of the grant or other agreement, insert N/A; then, show the ending of the accounting period to which this amount aggregate amounts. On a separate sheet, list each applies. Enter program ou~ays to date (net of refunds, grant or agreement number and the Federal share of rebates, and discounts), in the appropriate columns. outlays made against the grant or agreement. For requests prepared on a cash basis, outlays are the sum of actual cash disbursements for goods and 6 Enter the employer identification number assigned by services, the amount of indirect expenses charged, the the U.S. Intemal Revenue Service, or the FICE value of in-kind contributions applied, and the amount (institution) code if requested by the Federal agency. of cash advances and payments made to subcontractors and subrecipients. For requests 7 This space is reserved for an account number or prepared on an accrued expenditure basis, outlays are other identifying number that may be assigned by the the sum of the actual cash disbursements, the amount recipient. of indirect expenses incurred, and the net increase (or decrease) in the amounts owed by the recipient for 8 Enter the month, day, and year for the beginning and goods and other property received and for services ending of the period covered in this request. If the performed by employees, contracts, subgrantees and request is for an advance or for both an advance and other payees reimbursement, show the period that the advance will cover. If the request is for reimbursement, show the 11b Enter the cumulative cash income received to date, if period for which the reimbursement is requested. requests are prepared on a cash basis. For requests prepared on an accrued expenditure basis, enter the Note: The Federal sponsoring agencies have the option of cumulative income eamed to date. Under either basis, requiring recipients to complete items 11 or 12, but enter only the amount applicable to program income not both. Item 12 should be used when only a that was required to be used for the project or program minimum amount of information is needed to make an by the terms of the grant or other agreement. advance and outlay information contained in item 11 can be obtained in a timely manner from other 11d Only when making requests for advance payments, reports. enter the total estimated amount of cash outlays that will be made during the period covered by the advance. 11 The purpose of the vertical columns (a), (b) and (c), is to provide space for separate cost breakdowns Complete the certification before submitting this when a project has been planned and budgeted by 13 request. program, function, or activity. If additional columns are needed. STANDARD FORM 270 BACK (7-76) GC-10