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OMB APPROVAL NO. PAGE OF <br /> 0348-0004 1 2 PAGES <br /> REQUEST FOR ADVANCE ,,,-,,,,,,a,,,,,,, 29A515 OF REQUEST <br /> OR REIMBURSEMENT ~ ?ADVANCE m REIMBURSE- <br /> TYPEOF MENi OCASH <br /> PAYMEM S. Xtle applivhb EUr <br /> (See InsWCtlons on back) REOUESTEO ? FINAL ? PARTIAL ? ACCRUAL <br /> a. FEDERAL aPONBOmNG AGENCY AND ORGIWZlT10NAL ELEMEMTO d. FEDERAL GRANT OR OTHER 5. PARTIAL PAYMENT REQUEST <br /> WHICH TRIG REPORT 55UBMITTED IDBJIIFYING NUMBER ASSIGNED NVMBER FOR TWS REQUEST <br /> BV FEDERAL AGENCY <br /> USDA Rural Development Community Facilities Grant - Pahala 1 <br /> 6. EMPLOYER IOEfmFICATN7N T. REpPIENI'S ACCOUNrrJUMBER 8. PERIOD COVERED BY THIS REQUEST <br /> NUMBER OR IDENTIFYING NUMBER FROM (month, tlay yrad TO (monM, day, yerJ <br /> 99-6000567 610010996000567 05/20/2005 09/30/2007 <br /> D. REGPIENTIXtGANVATaNJ f 0. PAYEE (Where check is b be sentYdrrereM than ttem a) <br /> Name: County of Hawaii Fire Department Name: <br /> Number Number <br /> and Sheet 25 Aupuni Street, Room 103 and sheep. <br /> City, State City, Sfate <br /> eM LP Code: HflO, HI 96720 and LP Code: <br /> 11. COMPUTATION OF AMOUNT OF REIMBURSEMENTS/ADVANCES REQUESTED <br /> PROGRAMS/FUNCTIONS/ACTIVITIES ? <br /> Equipment Purchase TOTAL <br /> a. ToW program tAaddsb~ $ 24,995.36 $ $ $ 24 995.36 <br /> to date <br /> b. Less: Cumulagve ram income O.OO <br /> Net program outlays (f-ma a MnMS 24,995.36 0.00 0.00 24,995.36 <br /> Meb <br /> d. Estimated net cash outlays for advance _ O.OO <br /> e. Total Sum o/Ines c 8 ~ 24,995.36 0.00 0.00 24,995.36 <br /> f. Non-Fetlerel share of amoulrt on urge a 6,248.84 6,248.84 <br /> . Federal share of amount on ine a 18,746.52 18,746.52 <br /> h. Federal vb ted O.OO <br /> i. Federal snare now requested (une g 1$,746.52 0.00 0.00 18,746.52 <br /> minus ine h) <br /> <br /> I- Advances required by <br /> month, when requested lstmonth ~ O.OO <br /> by Federal grantor <br /> agency far use h making 2nd month O.OO <br /> presdroduled advances 3rd month O.OO <br /> 12. ALTERNATE COMPUTATION FOR ADVANCES ONLY <br /> <br /> a. Estimated Federal cash outla that will be made du ' rbd covered the advance $ <br /> b. Less: Estimated balance of Federal cash on hand as of fmJ of advance <br /> e. Amount nested ne a minus ine b) $ O.OO <br /> <br /> AUTHORED FOR LOCAL REPRODUCTION (COntlnued on Reverse) STANDARD FORMYla tRe+. 7-97) <br /> Prescribed by OMB Circulars A-102 and A-110 <br /> <br />