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REQUEST FOR FUNDS NORTH DAKOTA DEPARTMENT OF PUBLIC INSTRUCTION FISCAL MANAGEMENT SFN 14660 Rev. 8/2012 Requesting Agency Project Number and Program Title As it appears on Grant Award Contact Person Mailing Address City State Budget/Project Period MM/DD/YYYY To From Fiscal Year Final Request Reporting Period of Expenditures for this Request MM/DD/YYYY Yes ZIP Code Telephone Number No A. Total amount of award including revisions and/or carry-over if applicable. B. Cumulative expenditures expenditures from start of this budget/project period through the end of this C. Unpaid obligations being claimed for payment Must be zero on final request. D. Prior payments received for this grant. E* Amount of this request Line B plus Line C less Line D. F* Balance remaining Line A less Lines B and C. written* If this is federal program funds funds for the unpaid obligations must be disbursed within 3 days of receipt of funds. The final request for funds may not include unpaid obligations. Reimbursement claims for funds expended through June 30 of any year must be submitted to the Department of Public Instruction by July 15. This section to be completed only for requests submitted in July and August. 1. Are all funds requested on Line E above for costs incurred prior to June 30 2. If no please indicate the amount of the request which applies to the new fiscal year beginning July 1 Remarks I hereby certify the following 1 The requesting agency has authorized me as its representative for this project/program* 2 That state and federal rules and regulations applicable to the use of these funds were observed* 3 Documentation for reported expenditures and obligations are available for audit review. Typed Name of Authorized Representative Title Signature of Authorized Representative For Department Use Only Date Total Payment Approved Account Class 20167 Signature of DPI Representative CFDA Dept ID Fund Project ID Activity ID Payment Approved. Total amount of award including revisions and/or carry-over if applicable. B. Cumulative expenditures expenditures from start of this budget/project period through the end of this C. Unpaid obligations being claimed for payment Must be zero on final request. D. Prior payments received for this grant. Unpaid obligations being claimed for payment Must be zero on final request. D. Prior payments received for this grant. E* Amount of this request Line B plus Line C less Line D. F* Balance remaining Line A less Lines B and C. E* Amount of this request Line B plus Line C less Line D. F* Balance remaining Line A less Lines B and C. written* If this is federal program funds funds for the unpaid obligations must be disbursed within 3 days of receipt of funds. written* If this is federal program funds funds for the unpaid obligations must be disbursed within 3 days of receipt of funds. The final request for funds may not include unpaid obligations. Reimbursement claims for funds expended through June 30 of any year must be submitted to the Department of Public Instruction by July 15.

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