|
t3. CERTIFICATION
<br /> SIGNA7IXZE RAlm10R~DGERTIFYING GFFIGIAL DATE REWESr
<br /> I ceAity that to the best of my sueMrrreD
<br /> knowledge and belief the tlata on the
<br /> reverse are correct and that all outlays August 20, 2007
<br /> were made in BCCOrdanCe Wltll the OR PRI NA TIRE TELEPIpklE (AREA
<br /> grant cerld3iolls or omer agreement coot; uunlaER,
<br /> and that payment is due and Hors not Darryl J. Olivei ,Fire Chief I~CIErLSIONI
<br /> been prevbusry requested. (808)981-8394
<br />
<br /> This space for agency use
<br /> Pubrc reporting burden for tl>Is cdlection of Mformatlon is estimated to average 60 rMrtutes per
<br /> response, inGudirg time for reviewing ttstnectlons, searcNng etassdrg data sources, gathelvg and
<br /> tTRtkttaining the data needed, and completing and reviewing the celteetion of Infomtation. Send
<br /> contrnert5 regarding ate Darden estimate or any otlter aspect of tltis edleGMt of Infortrtatlon,
<br /> htclllding suggestions for reductg this burden, to the Office of Management and Budget, Paperwork
<br /> Reduction Project (0348-0004), Washington, DC 20503.
<br /> PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT
<br /> AND Bl1DCET. SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
<br /> INSTRUCTIONS
<br /> Please type or print legibly. ttems 1, 3, 5, 9, 10, 11e, 1 tf, 11g, 11 i, 12 and 13 are self-explanatory; specific
<br /> instructions for other items are as follows:
<br /> kem Entry Item Enay
<br /> 2 Indicate whether request is prepared on cash or accrued activity. If additional columns are needed, use as many
<br /> expenditure basis. All requests for advances shall be addttional forms as needed and indicate page number in
<br /> prepared on a rash basis. space provided in upper right; however, the summary
<br /> totals of all programs, functions, or activities should be
<br /> 4 Enter the Federal grant number, or other identifying shown in the "total" column on the first page.
<br /> number assigned by the Federal sponsoring agency. If
<br /> the advance or reimbursement is for more than one grant 11 a Enter in "as of date," the month, day, and year of the
<br /> or other agreement, insert N/A; then, show the aggregate ending of the accounting period to which this amount
<br /> amounts. On a separate sheet, list each grant or applies. Enter program outlays to date (net of refunds,
<br /> agreement number and the Federal share of outlays rebates, and discounts), In the appropriate columns. For
<br /> made against the grant or agreement requests prepared on a cash basis, outlays are the sum
<br /> of actual cash disbursements for goods and services,
<br /> 6 Enter the employer identification number assigned by the the amount of indirect expenses charged, the value of in-
<br /> U.S. Internal Revenue Service, or the FICE (institution) kind contributions applied, and the amount of cash
<br /> erode if requested by the Federal agency. advances and payments made to subcontractors and
<br /> subrecipients. For requests prepared on an accrued
<br /> 7 This space is reserved for an account number or other expenditure basis, outlays are the sum of the actual
<br /> identifying number that may be assigned by the recipient cash disbursements, the amount of Indirect expenses
<br /> incurred, and the net increase (or decrease) in the
<br /> 8 Enter the month, day, and year for the beginning and amounts owed by the recipient for goods and other
<br /> ending of the period covered in this request. If the request property received and for services performed by
<br /> is for an advance or for bout an advance and employees, contracts, subgrantees and other payees.
<br /> reimbursement, show the period that the advance will
<br /> cover. If the request is for reimbursement, show the ttb Enter the cumulative cash income received to date, if
<br /> period for which the reimbursement is requested. requests are prepared on a cash basis. For requests
<br /> prepared on an accrued expendtture basis, enter the
<br /> Note: The Federal sponsoring agencies have the option of cumulative income earned to date. Under etther basis,
<br /> requiring recipients to complete items 7 7 or 12, but not enter only the amount applicable to program income that
<br /> both. Item 12 should be used when only a minimum was required to be used for the project or program by
<br /> amount of information is needed to make an advance and the terms of the grant or other agreement.
<br /> outlay information contained in ttem 11 can be obtained in
<br /> atimelymannerfromotherreports. 11d Only when making requests for advance payments,
<br /> enter the total estimated amount of cash outlays that will
<br /> 11 The purpose of the vertical columns (a), (b), and (c) is to be made during the period covered by the atlvance.
<br /> provide space for separate cost breakdowns when a
<br /> project has been planned and budgeted by program, 13 Complete the certification before submitting this request.
<br /> function, or
<br /> aTANDARO FORM 27a (Rev. 7b7/ axk
<br />
<br />
|