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Get SF 270-102 1996-2024

Email SF-270 to HMEP. Grants dot. gov. PHMSA-SF-270 Approved by Office of Management and Budget. No. 80-R0183 REQUEST FOR ADVANCE OR REIMBURSEMENT See instructions on back 3. FEDERAL SPONSORING AGENCY AND ORGANIZATIONAL ELEMENT TO WHICH THIS REPORT IS SUBMITTED 6. EMPLOYER IDENTIFICATION NUMBER 7. RECIPIENTS ACCOUNT NUMBER OR IDENTIFYING TYPE OF PAYMENT REQUESTED PAGE a* x one or both boxes ADVANCE OF 2. BASIS OF REQUEST CASH b. x the appropriate box ACCRUAL FINAL PARTIAL 4. FED GRANT OR OTHER IDENTIFYING NUMBER ASSIGNED BY FED AGENCY 5. PARTIAL PAYMENT REQUEST NUMBER FOR THIS REQUEST 8. PERIOD COVERED BY THIS REQUEST From month day year To Month day year Advance Only month day year 9. RECIPIENT ORGANIZATION 10. PAYEE Where check is to be sent if different than item 9 Name Number and Street City State and ZIP Code 11. COMPUTATION OF AMOUNT OF REIMBURSEMENTS/ADVANCES REQUESTED PROGRAMS/FUNCTIONS/ACTIVITIES a* b. c* As of date Total program outlays to date Less Cumulative program income f* Net program outlays Line a minus Line b Estimated net cash outlays for advance period Total Sum of lines c d Non-Federal share of amount on line e g. Federal share of amount on line e h. Federal payment previously requested i. line g minus line h j. Advances required by month when requested by Federal grantor agency for use in making prescheduled advances d. e. a Planning b Training c TOTAL 1st month 2nd month 3rd month 12. ALTERNATE COMPUTATION FOR ADVANCES ONLY a* Estimated Federal cash outlays that will be made during period covered by the advance b. Less Estimated balance of Federal cash on hand as of beginning of advance period c* Amount requested Line a minus line b 13. CERTIFICATION I certify that to the best of my knowledge and belief the data above are correct and that all outlays were made in accordance with the grant conditions or other agreement and that payment is due and has not been previously requested* SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL DATE REQUEST SUBMITTED TYPED OR PRINTED NAME AND TITLE TELEPHONE AREA CODE NUMBER EXTENSION This space for agency use 270-102 VE 10/96 Standard Form 270 7-76 Prescribed by OMB Circular A-110. FEDERAL SPONSORING AGENCY AND ORGANIZATIONAL ELEMENT TO WHICH THIS REPORT IS SUBMITTED 6. EMPLOYER IDENTIFICATION NUMBER 7. RECIPIENTS ACCOUNT NUMBER OR IDENTIFYING TYPE OF PAYMENT REQUESTED PAGE a* x one or both boxes ADVANCE OF 2. RECIPIENTS ACCOUNT NUMBER OR IDENTIFYING TYPE OF PAYMENT REQUESTED PAGE a* x one or both boxes ADVANCE OF 2. BASIS OF REQUEST CASH b. x the appropriate box ACCRUAL FINAL PARTIAL 4. FED GRANT OR OTHER IDENTIFYING NUMBER ASSIGNED BY FED AGENCY 5. BASIS OF REQUEST CASH b. x the appropriate box ACCRUAL FINAL PARTIAL 4. FED GRANT OR OTHER IDENTIFYING NUMBER ASSIGNED BY FED AGENCY 5. PARTIAL PAYMENT REQUEST NUMBER FOR THIS REQUEST 8. PERIOD COVERED BY THIS REQUEST From month day year To Month day year Advance Only month day year 9. PARTIAL PAYMENT REQUEST NUMBER FOR THIS REQUEST 8. PERIOD COVERED BY THIS REQUEST From month day year To Month day year Advance Only month day year 9. RECIPIENT ORGANIZATION 10. PAYEE Where check is to be sent if different than item 9 Name Number and Street City State and ZIP Code 11. .

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