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FY 2004 EDI-SPECIAL PROJECT NO. B-04-SP-FL-0172 - GRANT AGREEMENT .. I Assistance Award/Amendment 1 . Assistance Instrument D Cooperative Agreement 3. Instrument Number ~. B-04~SP-FL-0172 7. Name and Address of Recipient City of Clearwater 112 South Osceola Avenue Clearwater, FL 33758 EIN; 59-6000289 10. Recipient Project Manager William B. Horne 11. Assistance Arrangement o Cost Reimbursement o Cost Sharing 00 Fixed Price 14. Assistance Amount Previous HUD Amount HUD Amount this Action Total HUD Amount Recipient Amount Total Instrument Amount U.S. Department of Housing and Urban Development Office of Administration 2. Type of Action [X] Award 5. Effective Date of this Action [X] Grant 4. Amendment Number D Amendment 6. Control Number 8. HUD Administering Office CPO, EDI Special Project Division 451 7th Street, SW, Rm 7146 Washington, DC 20410-7000 8a. Name of Administrator 8b. Telephone Number 9. HUD Government Technical Representative Herbert Mallette 202-708-3773, Extension: 4885 12. Payment Method D Treasury Check Reimbursement D Advance Check [X] Automated Clearinghouse 13. HUD Payment Office Chief Financial Officier $447,345.00 $447,345.00 15. HUD Accounting and Apropriation Data 15a. Appropriation Number I 864/60162 Amount Previously Obligated Obligation by this Action Total Obligation $447,345.00 $447,345.00 15b. Reservation Number EID04 $447,345.00 16. Description by the City of Clearwater, Florida for waterfront facilities construction of the 'Beach by Design Initiative' This Award consists of the following items which are appended to and hereby made part of this Award: (A) Cover Page - HUD 1044 (B) Grant Agreement Special Conditions: Please contact Ubaldo Cazzoli - HUD Area Environmental Officer at 305-536-4652, concerning environmental review. NO FUNDS may be drawn down prior to environmental release of funds approval. 17 rYl . ~ Recipient is required to sign and return three (3) copies of this document to the HUD Administering Office. 19. Recipient (By Name): Mr. Willi m B, Horne 18'0 City Previous Editions are Obsolete 20. HUD (By Name): Donald P. Mains Date: Signature and Title: ~ /~) DAS for Economic Develo ~. FY 2004 EDI-SPECIAL PROJECT NO. B-04-SP-FL-0172 GRANT AGREEMENT This Grant Agreement between the Department of Housing and Urban Development (HUD) and City of Clearwater (the Grantee) is made pursuant to the authority of Public Law 108-199 (the FY 2004 Appropriations Act for HUD and other agencies) and House Report 108-401 (the Conference Report on the Appropriations Act). Please note that the Grant Amount shown below is 99.41 % of the amount specified in the Conference Report because of a .59% rescission mandated in the Act. The Grantee's application package, as may be amended by the provisions of this Grant Agreement, is hereby incorporated into this Agreement. In reliance upon and in consideration of the mutual representations and obligations hereunder, HUD and the Grantee agree as follows: Subject to the provisions of the Grant Agreement, HUD will make grant funds in the amount of $447,345 available to the Grantee. The Grantee agrees to abide by the following: ARTICLE I. HUD Requirements. The Grantee agrees to comply with the following requirements for which HUD has enforcement responsibility. A. The grant funds will only be used for activities described in the application, which is incorporated by reference and made part of this Agreement as may be modified by Article VII (A) of this Grant Agreement. B. EQUAL OPPORTUNITY REQUIREMENTS The grant funds must be made available in accordance with the following: 1. For projects involving housing, the requirements of the Fair Housing Act (42 US.c. 3601-20) and implementing regulations at 24 CFR Part 100; Executive Order 11063 (Equal Opportunity in Housing) and implementing regulations at 24 CFR Part 107. 2. The requirements of Title VI of the Ci viI Rights Act of 1964 (42 US.C. 2000d) (Nondiscrimination in Federally Assisted Programs) and implementing regulations issued at 24 CFR Part 1. 3. The prohibitions against discrimination on the basis of age under the Age Discrimination Act of 1975 (42 US.C. 6101-07) and implementing regulations at 24 CFR Part 146, and the prohibitions against discrimination against handicapped individuals under section 504 of the Rehabilitation Act of 1973 (29 US.C. 794) and implementing regulations at 24 CFR Part 8. ~- 4. The requirements of 24 CFR 5.105(a) regarding equal opportunity as well as the requirements of Executive Order 11246 (Equal Employment Opportunity) and the implementing regulations issued at 41 CFR Chapter 60. 5. For those grants funding construction covered by 24 CPR 135, the requirements of section 3 of the Housing and Urban Development Act of 1968, (12 U.S.C. 1701u) which requires that economic opportunities generated by certain BUD financial assistance shall, to the greatest extent feasible, be given to low- and very low-income persons and to businesses that provide economic opportunities for these persons. 6. The requirements of Executive Orders 11625 and 12432 (concerning Minority Business Enterprise), and 12138 (concerning Women's Business Enterprise). Consistent with BUD's responsibilities under these Orders, the Grantee must make efforts to encourage the use of minority and women's business enterprises in connection with grant funded activities. See 24 CFR Part 85.36(e) , which describes actions to be taken by the Grantee to assure that minority business enterprises and women business enterprises are used when possible in the procurement of property and services. 7. Where applicable, Grantee shall maintain records of its efforts to comply with the requirements cited in Paragraphs 5 and 6 above. C. ENVIRONMENTAL REVIEW REQUIREMENTS. 1. If the Grantee is a unit of general local government, a State, an Indian Tribe, or an Alaskan Native Village, the Grantee agrees to assume all of the responsibilities for environmental review and decision- making and actions, as specified and required in regulations issued by the Secretary pursuant to the Multifamily Housing Property Disposition Reform Act of 1994 and published in 24 CPR Part 58. 2. If the Grantee is a housing authority, redevelopment agency, academic institution, hospital, or other non-profit organization, the Grantee shall request the unit of general local government, Indian Tribe, or Alaskan Native Village, within which the project is located and which exercises land use responsibility, to assume all of the responsibilities for environmental review and decision-making as specified in paragraph C.l above, and the Grantee shall carry out all of the responsibilities of a recipient under 24 CFR Part 58. , D. Administrative requirements of OMB Circular A-133 "Audits of States, Local governments and Non-Profit Organizations." E. For State and Local Governments, the Administrative requirements of 24 CFR Part 85, including the procurement requirements of 24 CFR Part 85.36, and the requirements of OMB Circular A-87 regarding Cost Principles for State and Local Governments. For Non-Profits, the Administrative requirements of 24 CFR Part 84, including the procurement requirements of 24 CFR Part 84.40, and OMB Circular A-122 regarding Cost Principles for Non-Profit Institutions. For Institutions of Higher Education the applicable OMB Circular regarding Cost Principles is A-21. F. The regulations at 24 CFR Part 87, related to lobbying, including the requirement that the Grantee obtain certifications and disclosures from all covered persons. G. Restrictions on participation by ineligible, debarred or suspended persons or entities as described in Executive Order 12549 and at CFR 24 Part 5.105(c). H. The Uniform Relocation Act as implemented by regulations at 49 CFR Part 24. I. The Grantee will comply with all accessibility requirements under section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794) and implementing regulations at 24 CFR Part 8, where applicable. ARTICLE II. Conditions Precedent to Draw Down. The Grantee may not draw down grant funds until the following actions have taken place: A. The Grantee has received and approved any certifications and disclosures required by 24 CFR 87.100 concerning lobbying and by 24 CFR 24.51O(b) regarding ineligibility, suspension and debarment. B. Any other conditions listed in Article VII ( C ) of this Grant Agreement. ARTICLE III. Draw Downs. A. A request by the Grantee to draw down grant funds under the Voice Response Access system or any other payment system constitutes a representation by the Grantee that it and all participating parties are complying with the terms of this Grant Agreement. B. The Grantee will be paid on an advance basis provided that the Grantee minimizes the time elapsing between transfer of the grant funds and disbursement for project purposes and otherwise follows the requirements of 24 CFR Part 85 or Part 84 and Treasury Circular 1075 (31 CFR Part 205). C. Before the Grant Agreement is signed, the Grantee may incur cost for activities which are exempt from environmental review under 24 CFR Part 58 and may charge the costs to the grant. Funds provided by this grant however, may not be used for reimbursement of expenses incurred prior to the enactment of The Act authorizing these funds on January 23,2004. ARTICLE IV. Progress Reports. A. The Grantee shall submit to the Grant Officer a progress report every six months after the effective date of the Grant Agreement. Progress reports shall consist of (1) a narrative of work accomplished during the reporting period and (2) a completed Financial Status Report - Form 269 A. HUD may require additional information or increased frequency of reporting as described in Article VII ( C ). B. The performance reports must contain the information required under 24 CFR Part 85.40(b) (2) or 24 CFR Part 84.51(a), as applicable including a comparison of actual accomplishment to the objectives indicated in the approved application, the reasons for slippage if established objectives were not met, and additional pertinent information including explanation of significant cost overruns. C. No grant drawdowns will be approved for projects with overdue progress reports. ARTICLE V. Project Close-out. A. The grantee shall submit to the Grant Officer a written request to close-out the grant 30 days after the grantee has drawn down all funds and completed the activities described in the application, as may be amended. The final report shall consist of (1) a narrative of all work accomplished during the project period and (2) a completed Financial Status Report - Form 269 A covering the entire project period. HUD will then send the Close-out Agreement and Close-out Certification to the Grantee. At HUD's option, the Grantee may delay initiation of project close-out until the resolution of any HUD monitoring findings. If HUD exercises this option the Grantee must promptly resolve the findings. B. The Grantee recognizes that the close-out process may entail a review by HUD to determine compliance with the Grant Agreement by the Grantee and all participating parties. The Grantee agrees to cooperate with any review in any way possible, including making available records requested by HUD and the project for on-site HUD inspection. ..... C. The Grantee shall provide to HUD the following documentation: 1. A Certification of Project Completion. 2. A Grant Close-out Agreement. 3. A final financial report giving the amount and types of project costs charged to the grant (that meet the allowability and allocability requirements of OMB Circular A-122, A-87 or A-21 as applicable, including the "necessary and reasonable" standard); a certification of the costs; and the amounts and sources of other project funds. 4. A final performance report providing a comparison of actual accomplishments with each of the project commitments and objectives in the approved application, the reasons for slippage if established objectives were not met and additional pertinent information including explanation of significant cost overruns. D. The Grantee agrees that the grant funds are allowable only to the extent that the project costs, meeting the standard of OMB Circular A-122, A-87 or A-21 as applicable, equal the grant amount plus other sources of project funds provided. E. When HUD has determined that the grant funds are allowable, the activities were completed as described by the Grant Agreement, and all Federal requirements were satisfied, HUD and the Grantee will sign the Close-out Agreement and Close-out Certificate. E. The Close-out Agreement will include the Grantee's Agreement to abide by any continuing federal requirements. ARTICLE VI. Default. A default under this Grant Agreement shall consist of using grant funds for a purpose other than as authorized by this Agreement, any noncompliance with legislative, regulatory, or other requirements applicable to the Agreement, any other material breach of this Agreement, or any material misrepresentation in the application submissions. ARTICLE VII. Additional Provisions. A. Project Description. The project is as described in the application with the following changes: NONE B. Changes or Clarification to the Application Related to Participating Parties: The Administrative Agent if any: C. Special Conditions: NONE u.s. epartment of Ho ing and U an Developm t u.s. Department of Housing a:;jjj2~ AuthorlZea Signature Secretary Date City of Clearwater Mr. William B. Home !JJ.~~~-n: Authorized Signature City Manager Title -i~.- I &'1 zao(" Date ATTEST: - [. A4. Do Goudeau, City Clerk C-c.. Countersigned: t~ )(~.~ ~nk v. Hibbard, Mayor ,,,if,'~"r6,, 1.1111111\ ~~.IIII1IU) ~..,._.\l> U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT WASHINGTON, D.C. 20410-1000 .; J^ /J,)d~O{)-O<I OFFICE OF THE ASSISTANT SECRETARY FOR COMMUNITY PLANNING AND DEVELOPMENT APR 2 6 2005 Mr. William B. Home City Manager City of Clearwater 112 South Osceola Avenue Clearwater, FL 33758 Dear Mr. Home: The Department is pleased to announce approval of the following Special Project grant, as funded by the Congress in the VA-mID-Independent Agencies Appropriations Act for FY 2004 (PL 108-199) and as described in the Conference Report accompanying the Act (HR108- 401). Please note that the Grant Amount shown below is 99.41 % of the amount specified in the Conference Report because of a .59% rescission mandated in the Act. Project No.: B-04-SP-FL-0172 $447,345 Project Funding: Recipient: City of Clearwater This letter transmits the following documents and guidance needed to activate your FY 2004 special project grant. 1. Grant Agreement. Enclosed are four copies. Please read the agreement carefully, noting any attachments which have modifications or special conditions on this grant. Please sign and date three copies with original signatures and return them as noted below. The fourth copy is for your records pending receipt of a countersigned copy. 2. Assistance A ward - Form 1044. Four copies are enclosed. Please sign and date three copies with original signatures and return them as noted below. The fourth copy is for your records pending receipt of a countersigned copy. 3. Forms and Instructions for Drawing Down Funds. mID uses the Line of Credit Control System (LOCCS) for financial management of grant funds. Under this system, you identify the bank account into which you want mID to deposit funds electronically. Then you request scheduled payments, using a voice response system. L__un_ . You will be able to draw down funds once, 1) HUD processes the forms, 2) sends you a LOCCS ID Number and a LOCCS Voice Response Number, and 3) after the required certifications and environmental review (if needed) have been accepted by HUD. Please ensure that all the following forms are complete and return them together as noted below: a) the three signed originals of the Grant Agreement; b) the three signed originals of the Assistance A ward (HUD Form 1044); c) the Direct Deposit Form (SF 1199) completed by you and your financial institution; d) evidence of the ABA number for your depository account, such as a VOIDED blank check, a deposit slip or similar documentation. The notarized LOCCS Access Authorization Form (HUD form 27054) should be sent directly to the address on the form. All of these items should be sent to the Government Technical Representative for this grant, Herbert Mallette, Room 7146, U.S. Dept. of Housing and Urban Development, 451 Seventh Street, SW, Washington, DC 20410. If you or your staff have any questions about these documents and procedures, please contact Herbert Mallette at (202) 708-3773, ext. 4885, fax (202)-708-7543, or HerberCMallette@hud.gov. We look forward to working with you toward a successful completion of this project. onald P. Mains Deputy Assistant Secretary for Economic Development Enclosures c~.___ -- Assistance Award/Amendment U.S. Department of Housing and Urban Development Office of Administration 1. Assistance Instrument 2. Type of Action D D Cooperative Agreement 00 Grant 00 Award Amendment 3. Instrument Number 14. Amendment Number 5. Effective Date of this Action 16. Control Number B-04-SP-FL-0172 7. Name and Address of Recipient 8. HUD Administering Office City of Clearwater CPD, EDI Special Project Division 112 South Osceola Avenue 451 7th Street, SW, Rm 7146 Washington, DC 20410-7000 Clearwater, FL 33758 EIN: 59-6000289 8a. Name of Administrator 18b. Telephone Number 10. Recipient Project Manager 9. HUD Government Technical Representative William B. Horne Herbert Mallette 202-708-3773, Extension: 4885 11. Assistance Arrangement 12. Payment Method 13. HUD Payment Office D Cost Reimbursement D Treasury Check Reimbursement Chief Financial Officier D Cost Sharing D Advance Check 00 Fixed Price 00 Automated Clearinghouse 14. Assistance Amount 15. HUD Accounting and Apropriation Data Previous HUD Amount 15a. Appropriation Number I 15b. Reservation Number HUD Amount this Action $447,345.00 864/60162 EID04 Total HUD Amount $447,345.00 Amount Previously Obligated Recipient Amount Obligation by this Action $447,345.00 Total Instrument Amount $447,345.00 Total Obligation $447,345.00 16. Description by the City of Clearwater, Florida for waterfront facilities construction of the 'Beach by Design Initiative' This Award consists of the following items which are appended to and hereby made part of this Award: (A) Cover Page - HUD 1044 (B) Grant Agreement Soecial Conditions: Please contact Ubaldo Cazzoli - HUD Area Environmental Officer at 305-536-4652, concerning environmental review. NO FUNDS may be drawn down prior to environmental release of funds approval. --- "~.__..--- -"--- - ___n___.._"__ --_.._..~_.._- "--.- 17.~ Recipient is required to sign and return three (3) copies of 18. D Recipient is not required to sign this document. this document to the HUD Administering Office. 19. Recipient (By Name): 20. HUD (By Name): Mr. Willia.ffi B. Home Donald P. Mains Si~nat~~~~ Date: Signature and Title: Date: ~ 100tI) City a g DAS for Economic Development Previous Editions are Obsolete form HUD-1044 (8/90) Ref. Handbook 2210.17 Assistance Award/Amendment U.S. Department of Housing and Urban Development Office of Administration 1. Assistance Instrument 2. Type of Action D D Cooperative Agreement 00 Grant 00 Award Amendment 3. Instrument Number 14. Amendment Number 5. Effective Date of this Action 16. Control Number B-04-SP-FL-0172 7. Name and Address of Recipient 8. HUD Administering Office City of Clearwater CPD, EDI Special Project Division 112 South Osceola Avenue 451 7th Street, SW, Rm 7146 Washington, DC 20410-7000 Clearwater, FL 33758 EIN: 59-6000289 18b. Telephone Number 8a. Name of Administrator 10. Recipient Project Manager 9. HUD Government Technical Representative William B. Horne Herbert Mallette 202-708-3773, Extension: 4885 11. Assistance Arrangement 12. Payment Method 13. HUD Payment Office D Cost Reimbursement D Treasury Check Reimbursement Chief Financial Officier D Cost Sharing D Advance Check IX] Fixed Price 00 Automated Clearinghouse 14. Assistance Amount 15. HUD Accounting and Apropriation Data Previous HUD Amount 15a. Appropriation Number I 15b. Reservation Number HUD Amount this Action $447,345.00 864/60162 EID04 Total HUD Amount $447,345.00 Amount Previously Obligated Recipient Amount Obligation by this Action $447,345.00 Total Instrument Amount $447,345.00 Total Obligation $447,345.00 16. Description by the City of Clearwater, Florida for waterfront facilities construction of the 'Beach by Design Initiative' This Award consists of the following items which are appended to and hereby made part of this Award: (A) Cover Page - HUD 1044 (B) Grant Agreement SDecial Conditions: Please contact Ubaldo Cazzoli - HUD Area Environmental Officer at 305-536-4652, concerning environmental review. NO FUNDS may be drawn down prior to environmental release of funds approval. 1---------------------- ___m___._______..__._._ --. -- 17.~ Recipient is required to sign and return three (3) copies of 18. D Recipient is not required to sign this document. this document to the HUD Administering Office. 19. Recipient (By Name): 20. HUD (By Name): Mr. Wi liam B. Home Donald P. Mains Si~na~ I~~.. ~,i g ~ Date: Signature and Title: Date: CIty n'UlIU ger . -:II.. '/'2.-/0s-' DAS for Economic Development PrevIous Editions are Obsolete form HUD-1044 (8190) Ref. Handbook 2210.17 Assistance Award/Amendment 1. Assistance Instrument D Cooperative Agreement 3. Instrument Number B-04-SP-FL-0172 7. Name and Address of Recipient City of Clearwater 112 South Osceola Avenue Clearwater, FL 33758 EIN: 59-6000289 10. Recipient Project Manager William B. Horne 11. Assistance Arrangement D Cost Reimbursement D Cost Sharing 00 Fixed Price 14. Assistance Amount Previous HUD Amount HUD Amount this Action Total HUD Amount Recipient Amount Total Instrument Amount u.s. Department of Housing and Urban Development Office of Administration 2. Type of Action 00 Award 5. Effective Date of this Action 00 Grant 14. Amendment Number 12. Payment Method D Treasury Check Reimbursement D Advance Check 00 Automated Clearinghouse $447,345.00 $447,345.00 $447,345.00 D Amendment 16. Control Number 8. HUD Administering Office CPD, EDI Special Project Division 451 7th Street, SW, Rm 7146 Washington, DC 20410-7000 8a. Name of Administrator 18b. Telephone Number 9. HUD Government Technical Representative Herbert Mallette 202-708-3773, Extension: 4885 13. HUD Payment Office Chief Financial Officier 15. HUD Accounting and Apropriation Data 15a. Appropriation Number I 864/60162 Amount Previously Obligated Obligation by this Action Total Obligation 15b. Reservation Number EID04 $447,345.00 $447,345.00 16. Description by the City of Clearwater, Florida for waterfront facilities construction of the 'Beach by Design Initiative' This Award consists of the following items which are appended to and hereby made part of this Award: (A) Cover Page - HUD 1044 (B) Grant Agreement Soecial Conditions: Please contact Ubaldo Cazzoli - HUD Area Environmental Officer at 305-536-4652, concerning environmental review. NO FUNDS may be drawn down prior to environmental release of funds approval. --.. .-- .....-_._____...... ..__m._~_._..___.... 17. I)(l Recipient is required to sign and return three (3) copies of 18. D ~ this document to the HUD Administering Office. 19. Recipient (By Name): Mr. ~lliamB. Home Signat...&.&fti1Jj;.. B ~ ".-r~;_ ~u City M"anager . . .:II. Previous Editions are Obsolete Recipient is not required to sign this document. 20. HUD (By Name): Donald P. Mains Date: Signature and Title: '/2/ DS- DAS for Economic Development Date: form HUD-1044 (8190) Ref. Handbook 2210.17 Assistance Award/Amendment U.S. Department of Housing and Urban Development Office of Administration 1. Assistance Instrument 2. Type of Action D Cooperative Agreement [Xl Grant [Xl Award D Amendment 3. Instrument Number 14. Amendment Number 5. Effective Date of this Action 16. Control Number B-04-SP-FL-0172 7. Name and Address of Recipient 8. HUD Administering Office City of Clearwater CPO, EDI Special Project Division 112 South Osceola Avenue 451 7th Street, SW, Rm 7146 Clearwater, FL 33758 Washington, DC 20410-7000 EIN: 59-6000289 18b. Telephone Number 8a. Name of Administrator 10. Recipient Project Manager 9. HUD Government Technical Representative William B. Horne Herbert Mallette 202-708-3773, Extension: 4885 11. Assistance Arrangement 12. Payment Method 13. HUD Payment Office D Cost Reimbursement D Treasury Check Reimbursement Chief Financial Officier D Cost Sharing D Advance Check [XJ Fixed Price [Xl Automated Clearinghouse 14. Assistance Amount 15. HUD Accounting and Apropriation Data Previous HUD Amount 15a. Appropriation Number I 15b. Reservation Number HUD Amount this Action $447,345.00 864/60162 EID04 Total HUD Amount $447,345.00 Amount Previously Obligated Recipient Amount Obligation by this Action $447,345.00 Total Instrument Amount $447,345.00 Total Obligation $447,345.00 16. Description by the City of Clearwater, Florida for waterfront facilities construction of the 'Beach by Design Initiative' This Award consists of the following items which are appended to and hereby made part of this Award: (A) Cover Page - HUD 1044 (B) Grant Agreement SDecial Conditions: Please contact Ubaldo Cazzoli - HUD Area Environmental Officer at 305-536-4652, concerning environmental review. NO FUNDS may be drawn down prior to environmental release of funds approval. ---- -....--..-..-.- ---------- _ n .. ~_____ ------------ 17. [8] Recipient is required to sign and return three (3) copies of 18. D Recipient is not required to sign this document. this document to the HUD Administering Office. 19. Recipient (By Name): 20. HUD (By Name): Mr. William B. Home Donald P. Mains Si~n~. ~. ~-:II.. Date: Signature and Title: Date: Cl t y eT ~*C DAS for Economic Development Previous Editions are Obsolete form HUD-1044 (8/90) Ref. Handbook 2210.17 ... . ... EDI SPECIAL PROJECTS QUESTIONS AND ANSWERS THIS LIST CONTAINS SOME OF THE MOST FREQUENTLY ASKED QUESTIONS PERTAINING TO THE EDI-SPECIAL PROJECT GRANTS. 1. WHAT IS THE START OR EFFECTIVE DATE OF THE GRANT? ANSWER: THE EFFECTIVE DATE IS WHEN HOD SIGNS OFF ON THE GRANT AGREEMENT. TInS DATE IS IN BLOCK 5, HUD FORM 1044 (ASSISTANCE AWARD). 2. WHAT IS THE ENDING DATE? ANSWER: THE ENDING DATE IS FIVE YEARS AFTER THE GRANT FUNDS HA VB BEEN OBUGA TED. ANY UNSPENT GRANT FUNDS WOULD THEN BE SUBJECT TO RETURN TO THE U.S. TREASURY. 3. WHAT IS THE PROCEDURE FOR AN APPLICANT TO MAKE CHANGES TO THE BUDGET AND TIME LINES? ANSWER: THE APPUCANT MUST SUBMIT A LETTER REQUESTING REVISIONS TO THE BUDGET AND TIME UNES, ALONG WITH A JUSTIFICATION FOR THE PROPOSED CHANGES. 4. WHAT IS THE CFDA NUMBER? ANSWER: THE CFDA NUMBER IS 14.246. 5. WHAT IS THE 3-DIGIT VOUCHER PREFIX? ANSWER: THE 3-DIGIT VOUCHER PREFIX IS ''080''. 6. WHAT IS THE BUDGET LINE ITEM NUMBER? ANSWER: THE BUDGET LINE ITEM OR (BU) NUMBER IS 4246. t 7. WHEN SHOULD AN APPLICANT BEGIN PROCESSING THEIR ENVIRONMENTAL REVIEW FORMS? ANSWER: APPUCANT SHOULD GET THE PROCESS STARTED RIGHT A WAY ON THE ENVIRONMENTAL REVIEW. TillS REVIEW MUST BE COMPLETED BEFORE FUNDS CAN BE DRA WNDOWN. 8. WHOSE NAME AND SOCIAL SECURITY NUMBER SHOULD APPEAR ON THE LOCCS A UTHORIZA nON FORM (27054)? ANSWER: AN INDIVIDUAL DESIGNATED BY YOU TO DO DRAWDOWNSONBERMYOFYOURORGA~ATIONANDTHE PERSON WHO APPROVES THE DESIGNATED USER. 9. ARE THERE REPORTING REQUIREMENTS FOR TIDS GRANT? ANSWER: PROGRESS REPORTS ARE DUE ON A SEMI-ANNUAL BASIS. THEY SHOULD BE SENT TO THE ATTENTION OF THE GOVERNMENT TECHNICAL REPRESENT A TIVE (BLOCK 9 - ASSISTANCE AWARD, HUD-1044 FORM) AT THE FOILOWING ADDRESS: DEPT. OF HOUSING & URBAN DEVELOPMENT. ROOM 7146. 451 7TH STREET. SW.. WASHINGTON. DC 20410. LOCCS WILL SEND A REMJNDER LEITER 30-DA YS IN ADVANCE OF THE PROGRESS DUE DATE. A NARRATIVE ON PROGRESS WITHIN THE TIME PERIOD, A COMPLETED 269A FORM, AND COPIES OF THE 27053 FORM (IF YOU MADE DRA WDOWNS) IS REQUIRED. NO DRA WDOWNS WILL BE APPROVED IF SEMI-ANNUAL PROGRESS REPORTS ARE OUTSTANDING. 10. IS A REPORT REQUIRED IF NO ACTIVITY HAS TAKEN PLACE ON THE GRANT? ANSWER: YES, THE GRANTEE SHOULD INFORM HUD THAT NO ACTIVITY HAS TAKEN PLACE ON THE PROPOSED ACTIVITIES AND/OR NO MONEY HAS BEEN DRA WNDOWN. :J- II. 11. IF AN ENTITY IS A WARDED MORE THAN ONE EDI SPECIAL PROJECT GRANT IN THE SAME PROGRAM YEAR, CAN THEY BE COMBINED? ANSWER: NO, EACH EDI IS A SEPARATE APPUCATION AND AS SUCH, IS TO BE PROCESSED SEPARATELY. 12. HOW DO I CLOSE OUT THE EDI-GRANT? ANSWER: AFTER ALL EDI-FUNDS HAVE BEEN DRA WNDOWN, THE GRANTEE SHOULD SUBWT A 269A FORM TO THE GOVERNMENT TECHNICAL REPRESENTATIVE. IN BLOCK 12 STATE, "TO INITIATE PROJECT CLOSEOUT." THE GOVERNMENT TECHNICAL REPRESENTATIVE Wll..L THEN FORWARD THE NECESSARY FORMS TO COMPLETE CLOSE-OUT. 13. IF WE ARE ALREADY SETUP IN THE LOCCS SYSTEM WITH OTHER HUD PROGRAMS (CDBG, HOMELESS, ETC) DO WE STILL HA VE TO FILL OUT THE FINANCIAL FORMS AGAIN? ANSWER: YES, THE DIRECT DEPOSIT FORM (1199) AND 27054 MUST BE FILLED OUT AGAIN IN ORDER TO GAIN ACCESS TO THE EDI . SPECIAL PROJECT GRANT FUNDS. IF YOU WERE AWARDED AN EDI-SPECIAL PROJECT GRANT IN 1998 OR 1999 AND YOU ARE CURRENTLY SET UP IN LOCCS SYSTEM, NO ADDITIONAL FORMS (1199 OR 27054) ARE NECESSARY. 14. IF AN APPLICANT HAS A SUB GRANTEE, DOES HUD WANT THE CERTIFICATIONS TO BE FILLED OUT FOR THEM AS WELL? ANSWER: NO, CERTIFICATIONS SHOULD BE SIGNED AND DATED BY THE TARGETED RECIPIENT. 3 . l 15. HOW CAN THE GRANTEE OBTAIN THE 10-DIGIT VRS GRANT NUMBER? ANSWER: IN ADDITION TO DRAW-DOWN CAPABILITY, LOCCSNRS ALLOWS GRANTEES TO QUERY THE SYSTEM FOR VARIOUS INFORMATION. BY SPECIFYING A TAX ID NUMBER, THE LAST ASSIGNED VRS NUMBER FOR THE SELECTED PROGRAM AREA IS GIVEN BY ELECTRONIC VOICE. TIllS IS USEFUL IF THE CALLER HAS NOT RECEIVED THE LOCCSNRS GENERATED LETTER WITH THE ASSIGNED VRS NUMBER, BUT WISHES TO DRAW-DOWN FUNDS. l~ .~ PLEASE PASS ALONG THE FOLLOWING LOCCS INSTRUCTIONS AND TIPS TO THE STAFF MEMBER(S) WHO WILL BE DOING DRA WDOWNS ON BEHALF OF YOUR ORGANIZA TION. PLEASE REVIEW THE GRANTEE FINANCIAL INSTRUCTIONS CAREFULLLY, ALONG WITH THE Loces TIPS AND INSTRUCTIONS. 5 EDI-Special Projects TIPS FOR USING LOCCS 1. Activate LOCCS user-id immediately or before termination date listed on the initial letter from LOCCS. Failure to activate the user- id before the designated date will result in the user-id being terminated from the LOCCS system and requires re-application. 2. Your password must remain active. If the LOCCS system is not used for 60-days, your password will be suspended and access will be denied. Therefore, the user must enter the system and change the password, by entering an asterisk (*) preceding the current password. It is not necessary to do a drawdown. 3. If your password becomes inactive, the user must complete a new LOCCS Voice Response Access Authorization form (HUD-27054) requesting reset password. It does not need to be notarized but must be fully completed, signed, and dated. The form may be faxed to the LOCCS Security Office at (202) 708-4350. After the password is reset you will receive a letter that provides you with a temporary password for access into the LOCCS system. 4. If your user-id becomes inactive, the user must complete a new LOCCS Voice Response Access Authorization form (HUD-27054) requesting reinstate user. It must be fully completed, signed, dated and NOTARIZED. This action requires the form to be mailed. After the user-id is re-instated, you will receive a confirmation by mail. 5. The authorizing official must hold a higher position than the user. 6. Social Security Numbers are required for both the authorized user and the approving official. b 7. The LOCCS Security Help Desk telephone number is 1-877-705- 7504 (toll free). You should contact this office if the authorized user does not receive a user id to access the LOCCS system within 10 business days (after returning the completed BUD 27054 forms). All other questions should be directed to your Government Technical Representative (GTR). 7 TIPS for LOeeS Drawdown Requests . The LOeeSNRS number is 1- 877-705-7505 (toll free) or (301) 344- 0132. You may request a drawdown from 8:00 a.m. to 7:00 p.m. (eastern time) Monday through Friday. . LOeeS voucher request is selection number 1. . Enter your user ID and password when requested. (ID number will be sent to authorized user by LOeeS Security Office, HUD). . 080 is the three-digit program number. . LOeeS will give the caller a 6-digit voucher number. Please write this number down on the 27053 form. When prompted, entire the entire nine digits (080 plus the 6 numbers generated by the LOCeS system). . Enter the 10-digit LOeeSNRS Number. Grantee will receive this number by mail from HUD. If you do not have this number, grantee should do a query on the LOeeSNRS system. By specifying a Tax ID number, the last assigned VRS number for the selected program area is given by electronic voice. . Budget line item number is 4246. . Enter 9999 after line item request when prompted by system. . Any time that input is requested, one of the following can be used. #8 Repeat the last thing spoken #9 Return to previous menu selection #0 Quit immediately #1 Return to initial voice response menu selection q . Please call your Government Technical Representative (GTR) after your fITst drawdown request to have the voucher approved. The GTR must ascertain that all special conditions have been satisfied before approval. . If you are requesting 50% or more of the total grant award, a written statement detailing by budget line item what the the request will be used to pay must be provided to your Government Technical Representative (GTR) to verify immediate disbursement of the requested funds. The statement must be signed by an authorized official. (see Grantee Financial Instruction, Item 6, Restrictions on Drawdowns ). . No draws will be approved when a semi-annual report is outstanding. . No drawdowns will be approved without a release of funds approval from the local HUD office. . Funds are usually deposited in your account within 48 - 72 business hours after approval by the (GTR). . Detailed instructions concerning LOCeS can be found in the "Grantee Financial Instructions" which was included as an attachment in the grant award package. 1 ~ GRANTEE FINANCIAL INSTRUCTIONS EDI-SPECIAL PROJECTS Congratulations on the award of your EDI-special project grant (EDI-SP). The Department of Housing and Urban Development(HUD)looks forward to working with you in this important effort to improve your community. This document provides all of the instructions you need to receive your EDI-SP funds. EDI-special project funds will be wire transferred directly from the U.S. Treasury into your bank account; there is no need to mail and deposit checks. Your EDI-SP grant is administered by the Office of Community Planning and Development (CPD) in HUD Headquarters in Washington, DC. All correspondence should be sent to CPD at this address: U.S. Department of Housing and Urban Development Office of Community Planning and Development 451 Seventh Street SW, Room 7146 Washington, DC 20410 The telephone number is (202) 708-3773. This is not a toll-free call. Enclosed with this document are certain forms you will need to set up your EDI-special project account: 1. Loces Voice Response Access Authorization Form (HUD-27054). 2. Direct Deposit Sign-up Form (SF-1199A). 3. Request Voucher for Grant Payment (HUD-27053). 10 I. SUMMARY OF THE LOCCS/VRS PAYMENT SYSTEM All EDI-special project grantees will use LOCCS/VRS to request program funds. LOCCS stands for the Line of Credit Control System, and is the system HUD uses to disburse grant funds. VRS stands for the Voice Response System, and is the automated system used by grantees to request funds that are recorded in LOCCS. Grantees use VRS to request funds via a touchtone telephone. Synthesized text-to-speech dialogue is used to request payment data from the caller. VRS requires the caller to enter a User ID, password, and a VRS grant number to ensure that the caller has authority to request grant funds for the particular EDI- special project grant. The requested payment amount is checked against the grant's available balance in LOCCS to ensure that the request does not exceed the grant's authorized funding limits. LOCCS will not allow more than one draw per g~ant per day. Once the reauest is annroved. funds are wired from the u.s. Treasury directlY into the arantee's bank account. usually within 48-72 hours fram the day the reauest is anDroved. II. USING THE VRS/BLI PAYMENT SYSTEM A. Preliminary Requirements 1. Creating your Account in LOCCS With this document, you should have received four copies of the EDI-SP Grant Agreement to sign and return. You are to retain one copy for your files. When HUD receives the remaining three signed copies, they will be executed (signed) and one executed copy will be returned to you. The effective date of the grant is the date the grant agreement was signed by HUD. HUD will enter information on the grant agreement, including name, address, and term, into LOCCS. HUD will also enter the amount awarded under one Budget Line Item CBLI) - 4246/EDI Special Projects. \ \ 2. User ID and Password Only users with valid User IDs and passwords may access LOCCS/VRS. Users are allowed access to only those programs, projects, and functions that have been requested and approved by the LOCCS Security Officer at HUD Headquarters. To gain authorization to LOCCS/VRS, each staff person of your organization who will perform "drawdown" functions must submit one LOCCS/VRS Access Authorization Form (HUD-27054). The LOCCS Authorization Form (HUD-27054) must be completed by both the staff who will have on-line access to LOCCS and those who authorize their staff to access LOCCS. Two copies of this form are enclosed, and a sample form has been completed for your information. It is recommended that two persons be authorized to draw down EDI-SP funds via VRS in case of illnesses, vacations, etc. Grantees will then have an alternate staff person authorized to drawdown funds. These camcleted . forms must be returned via overniaht delivery to: Chief Financial Officer. FYM. 451 7~ Street. S.W.. Roam 3114. Washinaton. DC 20410 or reaular mail to: U. S. Deoartment of Housina and Urban Develooment. Chief Financial Officer. FYM. P. O. Box 23774. Washinaton. DC 20026-3774.The teleohone number for LOCCS Security is 1-877-705-7504. The cOmDlete oackaae. that is. three cooies of the sianed arant aareements and the Direct Deoosit form (1199A) should be sent toaether (via Overniaht ExDress. Federal ExDress or UPS) to your Government Technical Reoresentative at the address on the front oaae of this document. Failure to submit all documents together will delay processing of your account and drawdown authorization. The LOCCS Security Officer will notify each individual who has submitted a Form HUD-27054 of their User ID via a User ID Authorization Letter to be opened by the addressee only. The letter will state that the user must access LOCCS by a certain date. If the system is not accessed by that time, their authorization will be canceled. The caller will not have to request a drawdown in order to access the system. The caller will, however, need to create a password. If you do not receive your password and User ID in a timely manner, please contact the HUD Security Officer at 1-877-705-7504 (toll free) or (202) 708-0764 to ensure the document has been I~ received. CPD cannot assist you with LOCCS/VRS security problems. 3. Voice Response Number Each grantee will also receive a letter containing his or her computer-generated Voice Response Number. LOCCS automatically assigns a unique all-numeric, 10-digit number to each grant whose program area participates in VRS. 4. Direct Deposit Form Each grantee must complete and submit a Direct Deposit Sign-Up Form (SF-1199A). This form identifies the bank account into which grant funds will be deposited. All funds will be wire transferred from the U.S. Treasury directly into the grantee's bank account. A copy of this form is enclosed, and a completed sample form to use as a guide. After the grantee has completed Section 1 and the grantee's financial institution has completed Section 3, return the form AND A BLANK CHECK marked CANCELLED or VOID to CPD. A deposit slip may be submitted instead of the voided check. The voided check or deposit slips are used for verification purposes. Failure to include these items may delay Drocessina of the for.ms. The completed form should be returned to the attention of your Government Technical Representative (GTR) at the address listed on page one of this document. B. Preparing the Voucher LOCCS VRS Request Voucher for Grant Payment(HUD- 27053) is used for EDI-SP VRS payments. This form is to be filled out before calling the LOCCS VRS to request payment. A completed sample is provided. You do not have to submit a copy to HUD before a drawdown; however, please xerox a copy of the completed voucher and submit it to HUD along with your semi-annual report. Two copies of the voucher are enclosed. Please make copies of the voucher form (HUD-27053) for future use. Note: Following each disbursement request, the grantee must keep the original voucher, with copies of invoices, receipts, and other relevant documentation of costs, on file. 1.3 C. Making the Call 1. VRS Equipment The LOCCS/VRS phone number is 1-877-705-7505 (toll free) or(301) 344-0132. Hours of operation for LOCCS VRS are 8:00 a.m. to 7:00 p.m. Eastern Time, Monday through Friday. After the initial greeting, a menu selection is given. LOCCS voucher entry is selection number 1. 2. ID, Password, and Program Area The caller must have a properly completed voucher in hand as a reference when making the call. LOCCS will first ask for the caller's User ID and password to verify that the caller is authorized to draw down EDI-special project funds. 3. Voucher Number LOCCS/VRS will ask the caller for the three- digit voucher prefix number; the caller enters "080". LOCCS/VRS will give the caller the remaining 6 digits of the voucher number. The caller must write the entire voucher number in Block 1 of the voucher for.m and then enter the entire 9-digit voucher number for verification. This procedure also ensures that each voucher number is unique. 4. Entering the VRS Number LOCCS/VRS will ask the caller to enter the 10-digit VRS number that the grantee received by mail. LOCCS/VRS will give the caller the grantee's EDI-SP grant number as verification. 5. Entering Budget Line Items LOCCS/VRS will then prompt the caller to enter the first 4-digit line item number. Your bUdget line item number is 4246. LOCCS/VRS verifies that it is a valid number for the grant type and for the program area. The line item's name is spoken back to the caller. The caller will then enter the amount of funds to be drawn against the Line Item, followed by a pound (#) sign. Since LOCCS/VRS does not know in advance the number of digits being entered, the caller must enter a pound sign (#) as P-( the last input to indicate they have completed entering digits. Drawdown amounts which are not whole dollars will use the asterisk (*) on the phone pad to represent the decimal point. For example, to request $28,569.15, the caller would enter: 2 8 5 6 9 * 1 5 # LOCCS/VRS then provides the caller with a voucher total amount for confirmation. The caller then has a final option to process or cancel the request. 6. Restrictions on Drawdowns a. A grantee may not make more than one paYment request per day. b. OMB Circular A-110 states that a grantee must make drawdowns as close in time as possible to its disbursements. It also emphasizes that LOCCS is designed so that grantees can draw down funds when needed. Funds drawn down should be disbursed in paYment of program costs within three days of receipt of funds. That is, grantees should not draw down funds unless they expect to payout those funds within three days. C. Zf YOU are reauestinG 50% or more of the total arant award. a written statement detailinG bv budGet line item what the reauest will be used to Day must be Drovided to your Government Technical ReDresentative (GRT) to verify 'hnn-diate disbursement of the reauested funds. The statement must be sianed bv an authorized official. 7. Program Edits LOCCS/VRS uses paYment controls to ensure that paYments are appropriate and consistent with EDI-SP guidelines. These controls are called paYment edits. Edits on budget line items are applied when the grantee requests funds through LOCCS/VRS. Specific program edits are as follows: a. Review Authority. All drawdown requests will be reviewed by HOD Staff before approval. 15 b. Total Amount Requested. LOCCS will automatically reject any payment request that exceeds the total amount authorized for the grant in the grant agreement. c. Reports. Grantees must submit semi-annual reports to the Government Technical Representative in Washington during the grant period and a Final Report at the end of the grant period. LOCCS/VRS will send grantees a system-generated letter regarding their semi- annual report. This letter will remind each grantee that their semi-annual report is due to HUD in 30 days. 8. Outcomes of a Request for Payment a . Approved: Once the drawdown request has been reviewed and approved by HOD staff, the requested funds are wired to the grantee's bank account, in most cases within 48-72 hours of the approval by HUD. Grantees are advised to call the Government Technical Representative (202) 708-3773 the first time a drawdown reques tis made. The Government Technical Representative will ascertain that all special conditions are met before approving the draw. b. Rejection: Drawdown requests will be 'rejected until special condition(s} are satisfied. Vouchers will be rejected for amounts that exceeds the total amount authorized in the grant agreement. c. Suspension: The grantee is unable to request any funds and is told that all further requests for funds have been suspended. This occurs when the grantee has failed to submit a report or is otherwise in violation of its grant agreement. Once the report is submitted or the violation is cured, the suspension will be lifted and the grantee may again request funds. - 110 IV. QUERIES In addition to drawdown capability, LOCCS/VRS allows grantees to query the system for various information. The initial menu will give grantees this option at the start of each VRS call. The available query functions are as follows: A. Grant Query LOCCS/VRS will give current authorized, disbursed, and available balance totals for the selected grant, along with general grant status. B. Voucher Query By entering a voucher number, the status of the voucher is given. This includes when the voucher was called in, by whom, and if the voucher has been paid, canceled, or is out for review. C. Last assigned VRS Grant Number By specifying a Tax ID number, your VRS number for the selected program area is given by electronic voice. This is useful if the caller has not received the LOCCS/VRS-generated letter with the assigned VRS number, but wishes to draw down funds. . V. CHANGE OF ADDRESS In the event that a grantee changes its address, the grantee must complete Form HUD-27056 (Change of Address Request) and submit it to CPD. The form is included. Please make a copy of it for use if and when you need to report a change in address. If you have any questions regarding the LOCCS/VRS Financial System, please call the Government Technical Representative for assistance, (202) 708-3773. If Attachments Attachment 1 Attachment 2 Attachment 3 Attachment 4 LIST OF ATTACHMENTS Grantee Financial Instructions Sample HUD-27054 (LOCCS Voice Response Access Authorization) Sample SF-1199A (Direct Deposit Sign-up Form) Sample HUD-27053 (Request Voucher for Grant Paymen t ) HUD-27056 (Change of Address Request) J ~ , . LOCCS Voice Response System Access Authorization ~~p\p t F OMS Approval No. 2535-0102 (exp. 03131/2007) See.lnstructions, Public Burden, and Privacy Act statements 'on back before completing this form This form is to be approved by the recipient's (or grantee's) chief executive oflicer. For new users and reinstate users, retain a copy and send a notarized original and one copy to your local HUO Field Office for review. U.S. Dept. of Housing and Urban Development Chief Financial Officer, FYM PO Box 23774 Washington, DC 20026-3774 For Overnight delivery send to: Chief Financial Officer, FYM 451 7th Street SW Room 3114 Washington, DC 20410 1. Type of Function (mark one) 2a. User 10 (Please leave blank) 2b. Social Security Number (SSN) 1 ~NOW u.., :8 Add new Program Area or Tax 10 (CFO USE ONLY) (mandatory) 2 Reinstate User Change Tax 10 /J3- ~-~ 78'< 3 T enninate User 70 Change Address 4 Reset Password for active users 80 Resend User.IO 3. Authorized User's Name (last, first, mil Print or Type Tille (mandatory) Office Telephone No. STh:M) L [leA,{ {j{t'AJL/ (J .J.a rd- (include area code) .. I. "9 E-Mail address (If available) s-- 01' /kt tlJh~ 4. Recipient Organization for which Authority is being Requested TaxlD I'J.. -3 51" Organization's Name TaxlD Organization's Name Tax 10 Organization's Name Sa. LOCCS Program Area 5c. Q = Query Only 5b. Program Name D = Project Drawdown S = Project Set-Up (HOME, HOP3) A = Admin. Drawdown (HOME, HOP3) 5;:' 5 (J iX tr; 3 6. Authorized User's Signature /5/ I Date (mmlddlyyyy) 6{)/ Of) I ~~ I authorize the person identified above to access LOCCS via the Voice Response System. 7. Office Telephone Number (include area code) 8. Notary (must be i erent from user and approving official) (Seal, Signature, and Date Notarized (mmlddlyyyy) E-Mail address (if available) Be 5U(~ rJotr;zc !I ~ 5"e'41. 5/6 tJ .J- d a k- Warning: HUO wiD prosecute false claims and statements. Conviction may result in aiminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802) Previous editions are obsolete. Page 1 of 1 form HUD-27054 (0612003) /4 LOCCS Voice Response System Access Authorization u.s. Department of Housing and Urban Development OMS Approval No. 2535-0102 (exp.03/3112007) See Instructions, Public Burden, and Privacy Act statements on back before completing this form This form is to be approved by the recipient's (or grantee's) chief executive officer. 'For new users and reinstate users, retain a copy and send a notarized original and one copy to your local HUD Field Office for review. u.s. Dept. of Housing and Urban Development Chief Financial Officer, FYM PO Box 23n4 Washington, DC 20026-3774 For Overnight delivery send to: Chief Financial Officer, FYM 451 7th Street SW Room 3114 Washington, DC 20410 . 1. Type of Function (mark one) . 1 ~ New User 2 Reinstate User 3 Terminate User 7 B 4 Reset Password for active users 8 3. Authorized User"s Name (laSt. first, mil Print or Type :8 Add new Program Area or Tax 10 Change Tax 10 Change Address Resend User-ID 28. User /0 (P~ase leave blank) (CFO USE ONLY) 2b. Social Security Number (SSN) (mandatory) TIlle (mandatory) Office Telephone No. (Include area code) Complete Mailing Address '--_(If..-l 4. Recipient Organization for which Authority is being Requested Tax \0 Organization's Nama Tax 10 OrganIzatlon'sName Tax 10 OrganIzatIon's Name 5c. Q = Query Only 5a.LOCCS Program Area 5b. Program Name D = Project Orawdown S = Project Set-Up (HOME, HOP3) A = Admin.Orawdown (HOME, HOP3) .;. 6. Authorized User's SlgIIIlture I Date (mmfdcllyyyy) I authorize the person identified above to access LOCCS via the Voice Response System. 7. Approved by name (Last. FIrSt. Mi.) Print or Type Office Telephone Number (Include area code) 8. Notary (must be diflerent from user and approving official) (Seal. Signature. and Date Notarized (mmlddlyyyy) TItle (mandatory) Social SecurIty Number (mandatory) Complete MaiHng Address E-MaI address (If available) Approving Official's Signature Date (mmldcllyyyy) Warning: HUD will prosecute taJse claims and statements. Conviction may IISUIt in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802) Previous editions are obsolete. Page 1 of 1 form HUD-27054 (0612003) dD LOCCS Voice Response System Access Authorization u.s. Department of Housing and Urban Development OMS Approval No. 2535-0' {expo 03/31/201 See Instructions, Public Burden, and Privacy Act statements on back before completing this form This form is to be approved by the recipient's (or grantee's) chief executive officer. For new users and reinstate users, retain a copy and send a notarized original and one copy to your local HUD Field Office for review. u.s. Dept. of Housing and Urban Development Chief Financial Officer, FYM PO Box 23774 Washington, DC 20026-3774 For Overnight delivery send to: Chief Financial Officer, FYM 451 7th Street SW Room 3114 Washington, DC 20410 . 1. Type of Function (mark one) ~~~:~:U~r ::~ 3 Tenninate User 4 Reset Password for active users 3. Authorized Users Name (last. first. mil Print or Type Add new Program Area or Tax 10 Change Tax 10 Change Address Resend User-IO 28. User 10 (Pleue leave blank) (CFO USE ONLY) 2b. Social Security Number (SSN) (mandatory) Title (mandatory) Office Telephone No. (include area code) Complete Malling Address ,........... In .-.oJ 4. Recipient Organization for which Authority is being Requested Tax 10 Organlzatlon's Name Tax 10 Organlzalion's Name Tax 10 Organization's Name Sa. LOCCS Program Area Sc. Q = Query Only 5b. Program Name D = Project Orawdown S = Project Set-Up (HOME, HOP3) A = Admin. Orawdown (HOME, HOP3) ". 6. Authorized User's SIgnature I Date (mmlddfyyyy) I authorize the person identified above to access LOCCS via the Voice Response System. 7. Approved by name (last. First. Mi.) Print or Type Office Telephone Number (Include area code) 8. Notary (muSl De dinerent from user and approving offICial) (Seal. Signature, snd Date Notarized (mmlddlyyyy) TItle (mandatory) Social Security Number (mandatory) Complete Mailing Address E-MaI eddress (If available) Approving Officiafs Signature Date (mmlddlyyyy) Warning: HUO will prosecute false claims and statements. Conviction may result in criminal and/or civJl penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802) Previous editions are obsolete. Page 1 of 1 form HUD-27054 (0612003) 9-1 LOCCS Voice Response System Access Authorization U.S. Department of Housing and Urban Development OMS Approval No. 2535-0102 (exp. 03/31/2007) See Instructions, Public Burden, and Privacy Act statements on back before completing this form This form is to be approved by the recipient's (or grantee's) chief executive officer. For new users and reinstate users, retain a copy and send a notarized original and one copy to your local HUD Field Office for review. U.S. Dept. of Housing and Urban Development Chief Financial Officer, FYM PO Box 23n4 Washington, DC 20026-3n4 For Overnight delivery send to: Chief Financial Officer, FYM 451 7th Street SW Room 3114 Washington, DC 20410 . 1. Type of Function (mark one) 28. User 10 (please leave blank) 2b. Social Security Number (SSN) 1 ~ New U." 5 B Add new Program Area or Tax 10 (CFO USE ONL V) (mandatory) 2 Reinstate User 6 Change Tax 10 3 Terminate User 7 0 Change Address 4 Reset Password for active users 80 Resend User-IO 3. Au1horized User's Name (last, first, mil Print or Type Title (mandatory) Office Telephone "'D. (include area code) Complete Mailing Address E-Mail address (If available) 4. Recipient Organization for which Authority is being Requested Tax 10 Organization's Name Tax 10 Organization's Name Tax 10 Organization's Name 5a.LOCCS Program Area 5c. Q = Query Only 5b. Program Name D = Proje:t Orilwdown S = Project Set-Up (HOME, HOP3) A = Admin.Drawdown (HOME. HOP3) ~ /. 6. Authonzed User's SlgrIlIture I Dale (mmldGlyyyy) I authorize the person identified above to access LOCCS via the Voice Response System. 7. Approved by name (Last, First, Mi.) Print or Type Office Telephone Number (include area code) 8. Notary (must be dlnerent from user and approving official) (Seal. Signature, and Dale Notarized (mmldlllyyyy) . Title (mandatory) Social Security Number (mandatory) Complete MaIling Address E.'" address (II available) Approving Official's Signature Dale (mmlddlyyyy) Warning: HUe will prosecute false claims and slatements. Convic:lion may result in criminal andlorcivi penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729, 3802) Previous editions are obsolete. Page 1 of 1 form HUD-27054 (0612003) ;:}...d.. OMS Approval No. 2535-0102 (exp. 01/31/20(4) u.s. Department of Housing and Urban Development S~it\fL~ Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions. searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not collect this information, and you are not required to complete this form. unless it displays a currently valid OMS control number. This information collection is to request payment of grant funds or to designate the appropriate officials who can have access to HUe voice activated payment system. The HUD voice activated payment system has been especially designed to help the recipient when calling in for a request of funds and improves the payment process so the recipient will know right away whether their request will be paid or not. This information collection is required under 24 CFR Subpart C. 85.21 - Post Award Requirements, the information collection is needed in order to obtain or retain a benefit. LOCCS VRS Request Voucher for Grant Payment by this Request (mmtyv)" Of NL to: 0 ~ l311Qff: 4tj~~dre55: 4a.Recipient OrganizatiOn's Employer Identification Number: 6. Voice Response No. (5 digits, hyphen, 5 digits) : Grant or Project No: (1) (2) (3) (4) (5) (6) (7) (8) (9) 5. Balance on Hand: $ Amount: (dOllars) (cents) * * * * * * * * * * $ ~S * $ ~5, o-rro I hereby certify that all the infonnation stated herein. as well as any infonnation provided in the accompaniment herewith. is true and accurate. Warning: HUD will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 U.S.C. 1001, 1010, 1012; 31 U.S.C. 3729. 3802) 7. Name & Title 01 AuthoriZed Signa1Dry (type or print clearly) -:r lA-d ~ ~b'ne.. S SIgnature Voucher Total: I-~- prl~CY A! ~lment: Public Law 97-255. Fmanciallntegrity Act. 31 U.S.C. 3512. authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions. The purpose of the data is to safeguard the Une of Credit Control System (LOCCS) from unauthorized access. The data are used to ensure that individuals who no longer require access to LOCCS have their access capability promptly deleted. Failure to provide the information requested on the form may delay the processing of your approval for access to LOCCS. While the provision of the SSN is voluntary. HUD uses it as a unique identifier for safeguarding the LOCCS from unauthorized access. This information will not be otherwise disclosed or released outside of HUD. excapt as permitted or required by law. Retain this form In your records for audit purposes form HUD-27053 (3193) 23 LOCCS VRS Request Voucher for Grant Payment u.s. Department of Housing and Urban Development Office of Administration OMS Approval No. 2535..01 (exp. 01/31/201 Public reporting burden for this collection of information is estimated to average 10 minutes per response. including the time for reviewing instructiol searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency rr not collect this information. and you are not required to complete this lorm. unless it displays a currently valid OMS control number. This information collection is to request payment of grant funds or to designate the appropriate officials who can have access to HUD voice activat payment system. The HUD voice activated payment system has been especially designed to help the recipient when calling in for a request of funds B improves the payment process so the recipient will know right away whether their request will be paid or not. This information collection is requir under 24 CFR Subpart C, 85.21 - Post Award Requirements, the information collection is needed in order to obtain or retain B benefit. 2. LOCCS Pgrm. Area: 3. Period Covered by !his Request (mmlyy): 110m: to: 4b. Recipient Organization'S Address: 4. Recipient Organization's Neme : 4a. Recipient Organization's Employer Identification Number: 5. Balance on Hanel : $ 6. Voice Response No. (5 digits. hyphen, 5 digits) : Grant or Project No: Amount: (dollars) (cent (1) $ * (2) * (3) * (4) * (5) * (6) * (7) * (8) * (9) * (10) * Voucher Total: $ * I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true an accurate. W.mlng: HUD will prosecute false c:IBims and statements. Conviction may resuh in criminal ancIIor civil penalties. (18 U.S.C. 1001, 1010, 101: 31 U.S.C. 3729. 3802) 7. Name & TIlle of Autl'lorizlld SignallOry (type or print deliII)') ~ I-~-- Prlv.cy Act 51.tement: Public Law 97 -255, Fmancial Integrity Act, 31 U.S.C. 3512. authorizes the Department of Housing and Urban Development (HUt: to collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actionl The purpose of the data is to safeguard the Une of Credit Control System (LOCeS) from unauthorized access. The data are used to ensure that individual who no longer require access to L.OCCS have their access capability promptly deleted. Failure to provide the information requested on the form may deJa the processing of your approval for access to L.OCCS. While the provision of the SSN is voluntary. HUD uses it as a unique identifier for safeguardin the LOCCS from unauthorized access. This information will not be otherwise disClosed or released outside of HUD, except as permitted or required b law. Retain this form In your records for audh purposes form HUD-27053 (319:: ;:2.1.1 Instructions for the Preparation and Submission of form HUD-27053, Request Voucher for Grant Payment 1. Enter a (9) digit two part number. Part 1 is the (3) digit prefix to your program. (If you do not know your (3) digit program prefix, contact your ProgramlGrant Officer). Part 2, the remaining (6) digits, will be assigned by LOCCSNRS during the telephone call. The entire (9) digit number will have to be enterF - :lrior to ending the call. 2. This block contains a maximum of 4-digit (xxxx) alphalnumeric program area identifier as stated in block 5a of the HUD-27054, LOCCS Voice Aesponse Access Authorization Form. 3. Enter the period covered by this request. 4. Enter the recipient organization's name as stated on the grant agreement. 4a. Aec:ipient Organization's Employer Identification Number (EIN) is the nine(9) digit number that is also known as the Tax Identification Number (TIN) in LOCCS-VAS and the Claim or Payroll 10 Number on the SF-1199A. 4b. Enter recipient organization's mailing address. 5. Enter the current balance of cash on hand. 6. Une 1: Enterthe 1o-digitVAS Number ofthe first project/grant for which funds are being requested. The first five digits of this number identify the grantee/recipient; the second five identify the specific project/grant. The first five digits should always be the same for a grantee/recipient. The second five digits should run consecutively for succeeding projects/grants within the program. Next, enterthe HUO project/grant numberforthe project. This entry is for confirmation purposes only and will not be entered into LOCCS-VAS through the touch-tone pad. Instead, when the VAS number is keyed in, the VAS simulated voice will speak the HUO project/grant number for the caller to ensure the correct VAS number was keyed. Finally, enter the amount requested for that particular project/grant. DoHars should be entered Iro the left of the asterisk (0) and cents to its right Unes 2 through 1 0: List any other project grants in the same HUD Program Area for which funds are to be requested. The total amount requested is entered in the lower right hand comer of Block 6. 7. Enter the authorizing signature and date of signature. The authorizing signatory in Block 7 can not be the same person(s) designated in Block 3 of the HUD-27054, LOCCS Voice Ae- sponse Access Authorization Form. Retain this tonn In your records for audit purposes form HUD-27053 (3193) d.5 LOCCS VRS Request Voucher for Grant Payment u.s. Department of Housing and Urban Development Office of Administration OMS Approval No. ~. (exp. 01/31120 Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructio searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency IT not collect this information, and you are not required to complete this form, unless it displays a currently valid OMS control number. This information collection is to request payment of grant funds or to designate the appropriate officials who can have access to HUe voice actival payment system. The HUe voice activated payment system has been especially designed to help the recipienl when calling in for a request of funds 8 improves the payment process so the recipient will know right away whether their request will be paid or not. This information collection is requir under 24 eFR Subpart e, 85.21 - Post Award Requirements, the information collection is needed in order to obtaip or retain a benefit. 2. LOCeS Pgrm. Area: 3. Period Covered by this Request (mmlyy): trom: to: 4b. Recipient Organiza~'s Addlllss: 4a.Recipient Organization's Employer Identification Number: 5. Balance on Hand : $ 6. Voice Response No. (5 digits, hyphen, 5 digits) : Grant or Project No: Amount: (dollars) (cent * * * * * * * * * * * $ Voucher Total: $ I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is trUe aDl accurate. Warning: Hue will prosecute false claims and statements. Conviction may result in criminal and/or civil penalties. (18 u.s.e. 1001, 1010, 101~ 31 u.s.e. 3729. 3802l 7. . Name & Tille of AuIhoriZ8d Signatory (type or prinI eIearly) -:- ,_d_ Privacy Act Statemerrt: Public Law 97-255, Financial Integrity Act, 31 u.s.e. 351 2, authorizes the Department of Housing and Urban Development (HUO to collect all the information (except the Social Security Number (SSN)) which will be used by HUe to protect disbursement data from fraudulent actions The purpose of the data is to safeguard the Une of Credit Control Systam (LOCCS) from unauthorized access. The data are used to ensure that individuall who no longer require access to LOeCS have their access capability promptly deleted. Failure to provide the information requested on the form may delal the processing of your approval for access to LOCeS. While the provision of the SSN is voluntary, HUD uses it as a unique identifier for safeguardinl the LOeeS from unauthorized access. This information will not be otherwise disclosed or released outside of HUe, except as permitted or required bl law. Retain this form In your records for audit purposes form HU~27053 (3193: ~b Instructions for the Preparation and Submission of form HUD-27053, Request Voucher for Grant Payment 1. Enter a (9) digit two part number. Part 1 is the (3) digit prefix to your program. (If you do not know your (3) digit program prefix, contact your Program/Grant Officer). Part 2, the remaining (6) digits, will be assigned by LOCCSNRS during the telephone call. The entire (9) digit number will have to be entered prior to eOO:19 the call. 2. This block contains a maximum of 4-c1igit (xxxx) alpha/numeric program area identifier as stated in block Sa of the HUD-27054, LOCCS Voice Response Access Authorization Form. 3. Enter the period covered by this request. 4. Enter the recipient organization's name as stated on the grant agreement. 4a. Recipient Organization's Employer Identification Number (EIN) is the nine(9) digit number that is also known as the Tax Identification Number (TIN) in LOCCS-VRS and the Claim or Payroll 10 Number on the SF-1199A. 4b. Enter recipient organization's mailing address. 5. Enter the current balance of cash on hand. 6. Line 1: Enter the 1 D-digit VRS Number of the first project/grant for which funds are being requested. The first five digits of this number identify the grantee/recipient; the second five identify the specific project/grant. The first five digits should always be the same for a grantee/recipient. The second five digits should run consecutively for succeeding projects/grants within the program. Next, enter the HUD project/grant numberforthe project. This entry is for confirmation purposes only and will not be entered into LOeeS-VRS through the touch-tone pad. Instead, when the VRS number is keyed in, the VRS simulated voice will speak the HUD project/grant number for the caller to ensure the correct VRS number was keyed. Finally, enter the amount requested for that particular project/grant. Dollars should be entered tro the left of the asterisk (.) and cents to its right. Lines 2 through 10: List any other project grants in the same HUD Program Area for which funds are to be requested. The total amount requested is entered in the lower right hand comer of Block 6. 7. Enter the authorizing signature and date of signature. The authorizing signatory in Block 7 can not be the same person(s) designated in Block 3 of the HUD-27054, LOCeS Voice Re- sponse Access Authorization Form. Retain this form In your records for .udlt purposes form HUD-27053 (3193) Ji{ LOCCS VRS Request Voucher for Grant Payment u.s. Department of Housing and Urban Development Office of Administration OMS Approval No. 2535-010 (exp. 01/31/2OOl Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instruction! searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency ma not collect this information, and you are not required to complete this form. unless it displays a currently valid OMS control number. This information collection is to request payment of grant funds or to designate the appropriate officials who can have access to HUD voice activat81 payment system. The HUD voice activated payment system has been especially designed to help the recipient when calling in for a request of funds ani improves the payment process so the recipient will know right away whether their request will be paid or not. This information collection is require. under 24 CFR Subpart C, 85.21 - Post Award Requirements, the information collection is needed in order to obtain or retain a benefit. Z. loces Pgrm. Area: 3. Period Covered by this Request (mmlyy): from: to: 4b. Recipient Organization's Address: 48. Recipient Organization's Employer Identification Number: 5. Balance on Hand: $ 6. Voice Response No. (5 digits, hyphen, 5 digits) : Grant or Project No: Amount: (dollars) (cents) * * * * * * * * * * * $ (8) (9) Voucher Total: $ I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate. Warning: HUD will prosecute faJse claims and statements. Conviction may result in criminal.nd/or civil penalties. (18 u.s.e. 1001, 1010, 1012; 31 U.S.C. 3729. 3802) 7. NlIme & TIlle of AuII1ori28d Signatory (type or print clelIrIy) ~ ,_<<_ Privacy Act Statement: Public Law 97-255, Fmanciallntagrity Act. 31 U.S.C. 3512. authorizes the Department of Housing and Urban Development (HUD} to collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions. The purpose of the data is 10 safeguard the Une of Credit Control System (LOCeS) from unauthorized access. The data are used to ensure that individuals who no longer require access to LOeeS have their access capability promptly deleted. Failure to provide the information requested on the form may delay the processing of your approval for access to LOCCS. While the provision of the SSN is voluntary, HUD uses it as a unique identifier for safeguarding the LOCCS from unauthorized access. This information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. Retain this form In your records for audit purposes form HUD-27053 (3193) act Instructions for the Preparation and Submission of fonn HUD-27053, Request Voucher for Grant Payment 1. Enter a (9) digit two part number. Part 1 is the (3) digit prefix to your program. (If you do not know your (3) digit program prefix contact your Program/Grant Officer). Part 2, the r~maining .' digits, will be assigned by LOCCSNRS during th,: "::thone c The entire (9) digit number will have to be entere( ir to endr the call. 2. This block contains a maximum of 4-cligit (xxxx) alpha/numeric program area identifier as stated in block Sa of the HUD-27054, LOCCS Voice Response Access Authorization Form. 3. Enter the period covered by this request. 4. Enter the recipient organization's name as stated on the grant agreement. 4a. Recipient Organization's Employer Identification Number(EIN) is the nine(9) digit number that is also known as the Tax Identification Number (TIN) in LOCCS-VRS and the Claim or Payroll 10 Number on the SF-1199A. 4b. Enter recipient organization's mailing address. 5. Enter the current balance of cash on hand. 6. Une 1: Enter the 1 O-cligit VRS Number of the first project/grant for which funds are being requested. The first five digits of this number identify the grantee/recipient; the second five identify the specific project/grant. The first five digits should always be the same for a grantee/recipient The second five digits should run consecutively for succeeding projects/grants within the program. Next, enterthe HUO project/grant numberforthe project. This entry is for confirmation purposes only and will not be entered into LOCCS-VRS through the touch-tone pad. Instead, when the VRS number is keyed in, the VRS simulated voice will speak the HUO project/grant number for the caller to ensure the correct VRS number was keyed. Finally, enter the amount requested for that particular project/grant. Dollars should be entered tro the left of the asterisk (.) and cents to its right. Woes 2 through 10: List any other project grants in the same HUO Program Area for which funds are to be requested. The total amount requested is entered in the lower right hand comer of Block 6. 7. Enter the authorizing signature and date of signature. The authorizing signatory in Block 7 can not be the same person(s) designated in Block 3 of the HUO-27054, LOCCS Voice Re- sponse Access Authorization Form. Retain this fonn in your records for audit purposes 10nn HUD-27053 (3193) ~9 ~H fYl" \"-- standanl Farm 1111A (EG) (Rlw. June 1887) "'-iIled by T_ry Depa- T.....,ry Oept Co. 1076 OMS No. 15104107 DIRECT DEPOSIT SIGN-UP FORM DIRECTIONS _ To sign up for Direct Deposit, the payee is to read the back of ttis fonn - The claim number and type of payment are prirWed on Gowmment and fill in the infonnetion requested in Sections 1 and 2. Then take or checks. (See the. sample check on the back of thIS form.) This mail this 10nn to the financial institution. The financial institlDm will infonnetion is also stated on benefici8ryJannuitant 8Wilrd letters and verify the infonnation in Sections 1 and 2, and will complete Section 3. other documem from the GO\iemmentagency. The completed fonn will be returned to the Gowmment agency identified below. . Payees must keep the Go\iemment agency informed of any address changes in order to receive important information about benefits and to remain qualified for paymerts. _ A separate form must be completed for each type of payment to be sent by Direct Deposit. A ZIP CODE F TYPE OF PAYMENT (Check only one) o Social Security 0 Fed. Sa....,lMiI. CiviIan P8y o Supplemenllll S_riIy 1_ 0 Mil Aclive o Railraad RelinJmenl 0 Mil. R8lint. o Civil Service Relirell'Wlnt (OPM) 0 Mil. Surv. o VA Co~saIion or Pension flil( OIlIer r- (spec G THIS BOX FOR AlLOTMENT OF PAYMENT ONLY (if epplicable) TYPE AMOUNT cg<1 D SuffIX PA YEElJOINT PAYEE CERnFICA TION JOINT ACCOUNT HOLDERS' CERnFICAnON (ofbona1) I certify that I have read and undel'lllDod the back of this form, including the SPECIAL NOnCE TO JOINT ACCOUNT HOLDERS. I certify that I am entitled to the payment identified above. and that I have read and understood the back of this farm. In signing this fonn. I authorize my payment to be sent to the fl18ncial instt&aion named below to be deposited to the designated account. SIGNATURE / DATE SIGNATURE DATE SIGNATURE DATE SIGNATURE DATE SEcnON 2 (TO BE COMPLETED BY PA YEE OR FINANCIAL INSTITUTION) GOVERNMENT AGENCY NAME GOVERNMENT AGENCY ADDRESS \1uj) J Or::r:: \C.~ of c...P D \..\5' 1*n S-tre.D I S W I ~'114 " I( P Q.t) nee:... o.-r Of"" po~, SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION) NAME AND ADDRESS OF ANANCIAL INSTITUTION. ROUTING NUMBER No-te I, -rne ~"'\( ~\A ST ~\ \ 1 \f\ ~\s ~e.<:.-t,~ DDDDODDD 0 DEPOSITOR ACCOUNT TITLE FINANCIAL INSmunoN CERTIRCA110N I confml the identity of the above-named payee(s) and the account number and tile. As representative of the ebove-named financial institution, I certify that the financial institution agrees to receive and deposit the payment identified above in ac:cordance with 31 CFR Parts 240, 209. and 210. PRINT OR TYPE REPRESENTATIVE'S NAME S SIGNATURE OF REPRESENTATIVE J FNnc:ia1 in8Iilulians should nIfer lllllle GREEN BOOK for fuIther inmuctions. - ~ GOVERI\IMENT AGENCY COPY TELEPHONE NUMBER DATE - NSN 754041.a5&-l7Z24 1199-207 o.igned IlIInll ~ PIo. 1M4SIDOR, M8,87 30 stancIIfd Fann 1189A (EG) (Rev. June 1887) P--.rbyT_ry ~ T-.ry o..t. CO". 1076 ~BNo.151~7 DIRECT DEPOSIT SIGN-UP FORM DIRECTIONS . To sign 14) for Direct Deposit, the payee is to read the back of tlis form . The claim number and type of payment are printed on Govemme~t and fill in the information requested in Sections 1 and 2. Then take or checks. (See the sample check on the back of thIS form.) This maR tns fonn to the financial institution. The financial insIiIUion wHI infonnation is also stated on beneficiary/annuitant award letters and verify the information in Sections 1 and 2, and will complete SecIion 3. other docUments from the Government agency. The completed fonn will be retLmed to the Government agency identified below. . Payees must keep the Govemment agency informed of any address changes in order to receive important information about benefits and to remain qualified for payments. . A separate form must be completed for each type of payment to be sent by Direct Deposit. A NAME OF PAYEE (last, first, middle initis/) o TYPE OF DEPOSITOR ACCOUNTD CHECKING D SAVINGS E DEPOSITOR ACCOUNT NUMBER ADDRESS (street, mute, P.O. Box, APOIFPO) I I I I I I I I I I II I I I I I I CITY STATE ZIP CODE F TYPE OF PAYMENT (Check only one) o Social Security o Fed. SalarylMiI. Civilan Pay TELEPHONE NUMBER o Supplemllnllll Securily Income o Mil. Active AREA CODE o RaillllBd ~ o Mil. Relinl. o CNS Selvice R8tmMnl (OPM) o Mil. Survivor B NAME OF PERSON(S) ENTITLED TO PAYMENT o VA CcImpenS8Iion or Pension o Other (spec;ty) C CLAIM OR PAYROLL 10 NUMBER G THIS BOX FOR ALLOTMENT OF PAYMENT ONLY (if applicable) TYPE I AMOUNT Prefix Suffix PA YEElJOINT PAYEE CERTIFICA noN JOINT ACCOUNT HOLDERS' CERTlFICA noN (optjonBQ I certify that I am entitled to the payment identified above. and that I have I certify that J have read and understood the back of this form, read and understood the back of this form. In sigrilll this form. I including the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS. authorize my payment to be sent to the financial ~ nemed below to be deposited to the designated accoWll SIGNATURE DATE SIGNATURE DATE SIGNATURE DATE SIGNATURE DATE SECTION 1 (TO BE COMPLETED BY PA YEE) SECTION 2 (TO BE COMPLETED BY PA YEE OR FINANCIAL INSTTTU770N) I GOIIE-..T AGENCY NAME I GOIIE-..T AGENCY AllDRESS NAME AND ADDRESS OF FINANCIAL INSTITUTION ROUTING NUMBER ~~*K DDDDODDD D DEPOSITOR ACCOUNT T1TLE FINANCIAL INSTITUTION CERT1FICATION I confirm the identity of the above-named payee(s) and the 8CICl:IW1t number and title. As representative of the above-ramed financial institution, I certify that the financial institution agrees to receive and deposit the payment identified above in accordance with 31 CFR Parts 240, 209. and 210. PRINT OR TYPE REPRESENTATIVE'S NAME I SIGNATURE OF REPRESENTATIVE I TELEPHONE NUMBER I DATE SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION) F"'3"oal insf . r inlllnlclions. NSN 75/11).01-1156-0224 GOVERNMENT AGENCY COPY 1199-207 c.;gMCI using IWform Pro. VIHSIDlOR, IoIar f1T 3 , ~ SF 1199A(Back) BURDEN ESTIMATE STATEMENT The estimated average burden associated with this collection of information is 10 minutes per respondent or record.keeper, depending on individual circumstances. Comments concerning the accuracy of this burden estimate a~~ suggestions for reducing this burden should be directed to the Financial Management Service, Facilities Management DIVIsIon, Property & Supply Section, Room 8-101, 3700 East-West Highway. Hyattsville, MD 20782 or the Office of Management and Budget, Paperwork Reduction Project (1510-0007), Washington, D.C. 20503. PLEASE READ THIS CAREFULLY All infonnation on this fonn, including the individual claim number. is required under 31 use 3322. 31 CFR 209 and/or 210. The intonnation is confidential and is needed to prove entitlement to payments. The infonnation will be used to process payment data from the Federal agency to the financial institution and/or its agent. Failure to provide the requested infonnation may affect the processing of this tonn and may delay or prevent the receipt of payments through the Direct DepositlElectronic Funds Transfer Program. INFORMATION FOUND ON CHECKS Most of the infonnation needed to complete boxes A, e. and F in Section 1 is printed on your govemment check: @ Be sure that payee's name is written exactly as it ap- pears on the cheek. Be sure current address is shown. @ Claim numbers and suffixes are printecl here on checks beneath the dale for the type of payment shown here. Check the Green Book for the location of prefixes and suffixes for other types of payments. <E> Type of payment is prirted to the left of the amount. United States Treasury V ~ I ~~wJ AUST~. TEXAS ~No. OOCIO 415785 L~ 28 28 COLLARS eTS "~of ( @ )C?I~"IEJ NOT NEGOTIABLE ':ClOlIDll51B': 041571828" SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS Joint account holders should immediately advise both the Government agency and the financial institution of the death of a beneficiary. Funds deposited after the date of death or ineligibility, except for salary payments. are to be returned to the Govemment agency. The Government agency will then make a determination regarding survivor rights, calaJlate survivor benefit payments. if any, and begin payments. CANCELLA nON The agreement represented by this authorization remains in effect until cancelled by the recipient by notice to the Federal agency or by the death or legal incapacity of the recipient Upon cancellation by the recipient, the recipient should notify the receiving financial institution that he/she is doing so. The agreement represented by this authorization may be cancellecl by the financial institution by providing the recipient a written notice 30 days in advance of the cancellation date. The recipient RlJst invnediately advise the Federal agency if the authorization is cancelled by the financial institution. The financial institution cannot cancel the authorization by advice to the Government agency. CHANGING RECEMNG FINANCIAL INSTITUTIONS The payee's Direct Deposit will continue to be receiwd by the selected financial institution until the Government agency is notified by the payee that the payee wishes to change the financial institution receiving the Direct Deposit. To effect this change, the payee will complete a new SF 1199A at the newly selected financial institution. It is recommended that the payee maintain accounts at both financial institutions until the transition is complete. i.e. after the new financial institution receives the payee's Direct Deposit payment. FALSE STA TEMENlS OR FRAUDULENT CLAIMS Federal law provides a fine of not more than $10.000 or imprisonment tor not more than five (5) years or both tor presenting a false.J~~';~~~?~;=~~~~'!~_4M~.~ r .....,....~~ ~_ J.JT 3a. SUncIaRt Form 11ll1A (EG) (Rev. ...... 1887) PMIcriIled DyT_ry o.p.- TIIlUIlry Dept. cr. 1076 OMS No. 1510.G007 DIRECT DEPOSIT SIGN-UP FORM DIRECTIONS . To sign up for Direct Deposit, the payee is to read the back ofitis fonn . The claim runber and type of payment are printed l?n Goll'llmmenl and fill in the infonnation requested in Sections 1 and 2. Then take or checks. (See the sample check on the back of thIS form.) ThIS maU this fonn 10 the financial institution. . The financial insIit\AiOn will infonnation is also staled on beneficiaryJannuilant award letters and verify the infonnation in Sections 1 and 2, and wRI complete Sec:lion 3. other documents from the Govemment agency. The compJeled fonn will be retllT1ed to the GoIIllmmenI agency identified below. . Payees must keep the Goll'llmment agency informed of any address changes in order to receive important information about benefits and 10 remain qualified for paymern. . A separate form must be completed for each type of payment 10 be sent by Direct Deposit. A NAME OF PAYEE (last, first, middle initial) o TYPE OF DEPOSITOR ACOOUNTD CHECKING 0 SAVINGS E DEPOSITOR ACCOUNT NUMBER ADDRESS (street. route, P.O. Box. APOIFPO) I I r I I I I I I I I I I I I I I I CITY STATE ZIP CODE F TYPE OF PAYMENT (Check only one) o Social Securiy o Fed. S8lary,w. Civiian Pay TELEPHONE NUMBER o Supplemenlal Security Income o Mil. Active AREA CODE o RaDnlIId Rem-nl o MiL Relile. o Civl Service Retirement (OPM) o Mil. Survivor B NAME OF PERSON(S) ENTITLED TO PAYMENT o VA Campenaalian or Pen&iDn OOlher (specify) C CLAIM OR PAYROll.ID NUMBER G THIS BOX FOR All.OTMENT OF PAYMENT ONLY (if applicable) TYPE I AMOUNT Prefix SuffIX PA YEElJOINT PAYEE CERnFICA nON JOINT ACCOUNT HOLDERS' CERTlFICA nON (optional) I certify that I am entil/ed to the payment identified aboll'll, and thiIIl hall'll I certify that I have read and understood the back of this form, read and understood the back of this fonn. In sigring this form, I including the SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS. a~rize my paymenllo be sent 10 the financial inslitI.Don named bebw 10 be deposited to the designated account. SIGNATURE DATE SIGNATURE DATE SIGNATURE DATE SIGNATURE DATE SECTION 1 (TO BE COMPLETED BY PA YEE) SECTION 2 (TO BE COMPLETED BY PA YEE OR FINANCIAL INSTITUTION) I GO\IERNMENT AGENCY NAME I GOIIERNo1ENT AGENCY AIlIlRESS NAME AND ADDRESS OF FINANCIAL INSTITUTION ROUTING NUMBER C~fi.K DDDDDDDD D DEPOSITOR ACOOUNT 11TLE FINANCIAL INS11TunON CERTIFICATION I confirm the idenlily of the above-named payee(s) and the aCCOU1t number and tiIIe. As representative ofthe abow-remed financial inslilution. I certify that the financial institution agrees 10 receive and deposit the payment identified aboll'll in accordance with 31 CFR Parts 240, 209, and 210. PRINT OR TYPE REPRESENTATIVE'S NAME I SIGNATURE OF REPRESENTATIVE I TELEPHONE NUMBER I DATE SECTION 3 (TO BE COMPLETED BY FINANCIAL INSTITUTION) NSN 7540.01~4 GOVERNMENT AGENCY COPY "99-207 Designed IIIIIlll PwtIann Pro, \I\HSIDIOR, _117 33 SF 1199A(Back) BURDEN ESTIMATE STATEMENT The estimated average burden associated with this collection of infonnation is 10 minutes per re~pondent or reco~keeper, depending on individual circumstances. Comments conceming the accuracy of thi~. .burden estimate a~~ ~uggestions for reducing this burden should be directed to the Financial Management Service, Facilities Management DMslon, Property & Supply Section, Room 8-101, 3700 East-West Highway, Hyattsville, MD 20782 or the Office of Management and Budget. PapelWOrk Reduction Project (1510-0007), Washington, D.C. 20503. PLEASE READ THIS CAREFULLY All information on this form, including the individual claim number, is required under 31 USC 3322, 31 CFR 209 and/or 210. The information is confidential and is needed to prove entitlement to payments. The information will be used to process payment data from the Federal agency to the financial institution and/or its agent. Failure to provide the requested information may affect the processing of this form and may delay or prevent the receipt of payments through the Dired DepositlElectronic Funds Transfer Program. INFORMATION FOUND ON CHECKS Most of the information needed to complete boxes A, C, and F in Sedion 1 is printed on your government check: @ Be SIZe that payee's name is written exactly as it ap- pears on the check. Be sure current address is shown. @ Claim numbers and sulIixes are pmted here on checks beneath the dale fer the type of payment shown here. Check the Green Book for the Ioc:abon of prefixes and suffixes for other types of paymenls. (E) Type of payment is prirted 10 the left of the amount. United States Treasury ~ ~ I [M[Eii!] I AUSTIN. TEXAS C J€)@ ~No. 0000 415785 "~ofC @ )c?l;::18 NOT NEGOTIABLE ':OCllIOO51lS': OC1571ll2lS" SPECIAL NOTICE TO JOINT ACCOUNT HOLDERS Joint account holders should immediately advise both the Government agency and the financial institution of the death of a beneficiary. Funds deposited after the date of death or ineligibility, except for salary payments, are to be retumed to the Government agency. The Government agency will then make a determination regarding survivor rights, calculate survivor benefit payments. if any, and begin payments. CANCELLATION The agreement represented by this authorization remains in effect until canceUed by the recipient by notice to the Federal agency or by the death or legal incapacity of the recipient Upon canceUation by the recipient, the recipient should notify the receiving financial institution that helshe is doing so. The agreement represented by this authorization may be cancelled by the financial institution by providing the recipient a written notice 30 days in advance of the cancellation date. The recipient must irrmediately advise the Federal agency if the authorization is cancelled by the financial institution. The financial institution cannot cancel the authorization by advice to the Government agency. CHANGING RECEIVING FINANCIAL INSTIllTnONS The payee's Direct Deposit will continue to be received by the selected financial institution until the Govemment agency is notified by the payee that the payee wishes to change the financial institution receiving the Direct Deposit. To effed this change, the payee will complete a new SF 1199A at the newly selected financial institution. It is recommended that the payee maintain accounts at both financial institutions until the transition is complete, i.e. after the new financial institution receives the payee's Direct Deposit payment. FALSE STA TEMENlS OR FRAUDULENT CLAIMS Federal law provides a fine of not more than $10,000 or imprisonment for not more than fIVE! (5) years or both for presenting a false.~~~:.~n.\~r,f!'~~~~;~ ~~len~i~~~_. _~~~~~_~:.~'V~-~..:t.'.. "'JIfdII~~-.'~' I 'at? '. . .... ~ ~ 3Y ....:)11111 r L~ FINANCIAL STATUS REPORT (Short Form) (Follow instructions on the back) 1. Federal Agency and OrganiZational Element 2. Federal Grant or Other Identifying Number OMB Approval .-1 of to Which Report is Submitted Assigned By Federal Agency No. 0348-0039 ] D4 S~ x. X 0 \~3 paAes 3. Recipient OrganiZation (Name and complete address. including ZIP code) c.:1~ of An lj W he ("~ Id-~ An'jwnef'e. S-tr~d ~1""\u wlrle.....P ~ y I:L~ l..\. t;" 4. Emplo1er Identification Number 5. Recipient Account Number or Identifying Number 6. Final Report 7. Basis I ~ - 3l.i ~bf"]<l q DYes o No o Cash o Accrual 8. Funding/Grant Period (See Instructions) I 9. Period Covered by this Report IT6~r;;i~) F~; I~~l ~7i Year) T~~i~~ I~ ;ear) 6F~1: ~M;'it;;.y, Year) 10. Transactions . I . II III Previously This Cumulative Reported Period a. Total outlays b. Recipient share of outlays c. Federal share of outlays d. Total unliquidated obligations e. Recipient share of unliquidated obligations 1. Federal share of unliquidated obligations g. Total Federal share (Sum of lines c and f) h. Total Federal funds authorized for this funding period i. Unobligated balance of Federal funds (Une h minus line g) a. Type of Rate (Place "X: in appropriate box) 11. Indirect OProvisionaJ [] Predetemined []FinaI [] FIXed Expense b. Rate Ic, Base _ Id. TotaJ~nt le.Fede~ - 12. Remarks: Attach any explanations deemed necessary or i1formation requil8d by Federal sponsoring agency in compliance with governing legislation. 13. Certification: I c:ertlfyto the best of my knowledge Md belief that this report 's correct MId complete.nc1 ........ outIIIys...d unllquld...c obligations .... tor the purposes ... forth In the _rd cIocumentL Typed or Printed Name and Title Telephone (Areacocle. number and extension) .JUt1\A TnnR.<; Signature of Authonzell Certifying QftI08I Date Report Submitted Is J OD(oDlt:4 Standard Form 269A (REV 4-88) Prescribed by OMB Circulars A-1 02 and A.11 0 35 FINANCIAL STATUS REPORT (Short Form) (FoUow instructions on the back) 1. Feeleral Agency and OrganiZational Element 2. Federal Grant or Other Identifying Number OMS Approval P"'I of to Which Report is Submitted Assigned By Feeleral Agency No. 0348-0039 pages 3. Recipient OrganiZation (Name and complete address. including ZIP code) 4. Employer Identification Number S. Recipient Account Number or Identifying Number 6. Final Report 7. Basis o Ves o No o Cash o Accrual 8. Funding/Grant Period (See Instructions) 9. Period Covereel by this Report From: (Month, Day, Year) To: (Month,Day,Yean From: (Month, Day, Vear) To: (Month. Day, Year) 10. Transactions I II III Previously This Cumulative Reported Period a. Total outlays b. Recipient share of outlays c. Federal share of outlays d. Total unliquidated obligations . e. Recipient share of unliquidated obligations f. Federal share of unliquidated obligations -. g. Total Feeleral share (Sum of lines c and f) . "..; , .. . h. Total Federal funds authorized for this funding period ..- .-.... . i. Unobligateel balance of Federal funds (Une h minus line g) d - . a. Type of Rate (Place ox- in appropriate box) o Predetermined DFNI o Fixed 11. Indirect o Provisional Expense b. Rate Ie. Base I d. Total Amount _ e. Federal Share 12. Remarks: AtIach any explanations deemecI necessary or information required by Fedel8l sponsoring agency in compliance with goveming 1egiIIation. 13. Certification: I certify to the best ofmy knowledge and belief that this report Is COI'nIC:Iancl complete and that all outlays and unliquidated obligations are for the purposes set forth In the award documenta. Typed or Printed Name and Title Telephone (Area code. number and extension) Signature of Authorized Certifying Official Date Report Submitted Standard Form 269A (REV 4-88) Prescribed by OMS Circulars A-1 02 and A-11 0 3~ FINANCIAL STATUS REPORT (Short Form) Please type or print legibly. The following general instructions explain how to use the form itself. You may need additional information to complete certain items correctly, or to decide whether a specific item is applicable to this award. Usually, such information will be found in the Federal agency's grant regulations or in the tenns and conditions of the award. You may also contact the Federal agency directly. Item Entry Item 1,2 and 3. Self-explanatory. 4. Enter the employer identification number assigned by the U.S. Internal Revenue Service. s. Space reserved for an account number or other identifying number assigned by the recipient. Check yes oniy if this is the last report for the period shown in item 8. Self-explanatory . Unless you have received other instructions from the awarding agency, enter the beginning and ending dales of the current funding period. If this is a multi-year program, the Federal agency might require cumulative reporting through consecutive funding periods. In that case, enter the beginning and ending dates of the grant period, and in the rest of these instructions, substitute the term "grant period" for "funding period." Self-explanatory . The purpose of columns, I, n and m is to show the effect of this reporting period's transactions on cumulative financial status. The amounts entered in column I will normally be the same as those in column m of the previous repon in the same funding period. If this is the first or only report of the funding period, leave columns I and n blank. If you need to adjust amounts entered on previous reports, footnote the column I entry on this report and attach an explanation. Enter total program outlays less any rebates, refunds, or other credits. For reports prepared on a cash basis, outlays are the sum of actual cash disbursements for direct costs for goods and services, the amount of indirect expense charged, the value of in-kind contributions applied, and the amount of cash advances and payments made to sub-recipients. For reports prepared on an accrual basis, outlays are the sum of actual cash disbursements for direct charges for goods and services, the amount of 6. 7. 8. 9. 10. lOa. lOb. lOc. 10d. Entry indirect expense incurred, the value of in-kind contributions applied, and the net increase or decrease in the amounts owed by the recipient for goods and other property recei ved, for services performed by employees. contractors, sub grantees and otherpayees, and other amounts becoming owed under programs for which no current services or performances are required, such as annuities, insurance claims, and other benefit payments. Self-explanatory . Self-explanatory . Enter the amount of unliquidated obligations, including unliquidated obligations to subgrantees and contractors. Unliquidated obligations on a cash basis are obligations incurred, but not yet paid. On an accrual basis, they are obligations incurred, but for which an outlay has not yet been recorded. Do not include any amounts on line lOd that have been included on lines lOa, b or c. On the final report, line 10d must be zero. IOe, f, g, h and i. Self-explanatory. lla. Self-explanatory. lIb. Enter the indirect cost rate in effect during the reporting period. He. Enter the amount of the base against which the rate was applied. Enter the total amount of indirect costs charged during the report period. Enter the Federal share of the amount in lId. Hd. He. Note: If more than one rate was in effect during the period shown in item 8, attach a schedule showing the bases against which the different rates were applied, the respective rates, the calendar periods they were in effect, amounts of indirect expense charged to the project, and the Federal share of indirect expense charged to the project to date. 31 Standard Form 269A (REV 4-88) Prescribed by OMB Cira,lIars A-102 and A.110 FINANCIAL STATUS REPORT (Short Form) (Follow instructions on the back) 1. Federal Agency and Organizational Bement 2. Federal Grant or Other Identifying Number OMS Approval Page ot to Which Report is Submitted Assigned By Federal Agency No. 0348-0039 pages 3. Recipient Organization (Name and complete address, including ZIP code) 4. Employer Identification Number 5. Recipient Account Number or Identifying Number 6. Final Report 7. Basis DYes oNo o Cash o Acaual 8. FundingfGrant Period (See Instructions) 9. Period Covered by this Report From: (Month, Day, Year) To: (Month, Day, Year) From: (Month, Day, Year) To: (Month. Day. Year) 10. Transactions I II III Previously This Cumulative Reported Period a. Total outlays b. Recipient share of outlays c. Federal share of outlays d. Total unliquidated obligations . ,.0, e. Recipient.hare of unliquidated obligations .. f. Federal share of unliquidated obligations " ..... g. Total Federal share (Sum of lines c and f) , .' . h. Total Federal funds authorized for this funding period .. . . .. i. Unobligated balance of Federal funds (una h minus line g) .' . . . a. Type of Rate (Place -X- in appropriate box) 11. Indirect o Provisional - o Predeterninecl DFNI o Faxed Expense b.Rate Ic.BlI8e Id. Total Amount e. Federal Share 12. Remarks: AItach any explanations deemed necessary or infu...oDon required by Federal sponsoring agency in compIiancawith governing legislation. 13. Certilic:ation: I eertlfyto the best of my knowledge end belief that this report Is ~.nd c:omplete .ndlhal all outlays end unIlquldatec obit_Ions are for the purposes eet forth In the awarel documents. Typed or Printed Name and Title Telephone (Area code. number and extension) Signature of Authorized Certifying Offrcial Data Report Submitted Standard Form 269A (REV 4-88) Prescribed by OMS Circulars A-1 02 and A-11 0 3<6 FINANCIAL STATUS REPORT (Short Form) Please type or print legibly. The following general instructions explain how to use the form itself. You may need additional information to complete certain items correctly, or to decide whether a specific item is applicable to this award. Usually, such information will be found in the Federal agency's grant regulations or in the terms and conditions of the award. You may also contact the Federal agency directly. - Item Entry Item Entry 1. 2 and 3. Self-explanatory. indirect expense incurred, the value of in-kind contributions applied, and the net increase or decrease in the amounts owed by the recipient for goods and other property received, for services performed by employees, contractors, subgrantees and other payees, and other amounts becoming owed under programs for which no current services or performances are required, such as annuities, insurance claims, and other benefit payments. lOb. Self-explanatory. lOco Self-explanatory. 9. 10. lOa. 4. Enter the employer identification number assigned by the U.S. Internal Revenue Service. 5. Space reserved for an account number or other identifying number assigned by the recipient. Check yes oniy if this is the last report for the period shown in item 8. 6. 7. Self-explanatory . 8. Unless you have received other instructions from the awarding agency, enter the beginning and ending dates of the current funding period. If this is a multi-year program, the Federal agency might require cumulative reporting through consecutive funding periods. In that case, enter the beginning and ending dates of the grant period, and in the rest of these instructions, substitute the term "grant period" for "funding period." Self-explanatory . The purpose of columns, I, n and ill is to show the effect of this reporting period's transactions on cumulative financial status. The amounts entered in column I will normally be the same as those in column ill of the previous report in the same funding period. If this is the first or only report of the funding period, leave columns I and n blank. If you need to adjust amounts entered on previous reports, footnote the column I entry on this report and attach an explanation. Enter total program outlays less any rebates, refunds, or other credits. For reports prepared on a cash basis, outlays are the sum of actual cash disbursements for direct costs for goods and services, the amount of indirect expense charged, the value of in-kind contributions applied, and the amount of cash advances and payments made to sub-recipients. For reports prepared on an accrual basis. outlays are the sum of actual cash disbursements for direct charges for goods and services. the amount of lOd. Enter the amount of unliquidated obligations, including unliquidated obligations to sub grantees and contractors. Unliquidated obligations on a cash basis are obligations incurred, but not yet paid. On an accrual basis, they are obligations incurred, but for which an outlay has not yet been recorded. Do not include any amounts on line IOd that have been included on lines lOa, b or c. On the final report. line IOd must be zero. lOe, f, g, h and i. Self-explanatory. 118. Self-explanatory. II b. Enter the indirect cost rate in effect during the reporting period. Hc. Enter the amount of the base against which the rate was applied. Enter the total amount of indirect costs charged during the report period. Enter the Federal share of the amount in lId. lld. lle. Note: If more than one rate was in effect during the period shown in item 8, attach a schedule showing the bases against which the different rates were applied, the respective rates, the calendar periods they were in effect, amounts of indirect expense charged to the project, and the Federal share of indirect expense charged to the project to date. Standard Form 269A (REV 4-88) Prescribed by OMB Circulars A-102 and A.11 0 39 ~ FINANCIAL STATUS REPORT (Short Form) (Follow instructions on the back) 1. Federal Agency and Organiza1ional Element 2. Federal Grant or Other Identifying Number OMS Approval -I of to Whieh Report is Submitted Assigned By Federal Agency No. 0348-0039 pages 3. Recipient Organization (Name and complete address. including ZIP code) 4. Employer Identification Number 5. Recipient Account Number or Identifying Number 6. Final Report 7. Basis o Ves oNo o Cash o Acaual 8. Funding/Grant Period (See Instructions) ,. 9. Period Covered by this Report From: (Month, Day, Year) To: (Month, Day, Year) From: (Month, Day, Vear) To: (Month.Day,Vea~ 10. Transactions I II III Previously This Cumulative Reponed Period a. Total outlays b. Recipient share of outlays c. Federal share of outlays d. Total unliquidated obligations e. Recipient share ofunliquidaled obligations ,. f. Federal share of unIiquidaIedobligations ,;.. ~ : : .. ,..,' g. Total Federal share (Sum of lines e and f) ...; . .. ". :.. h. Total Federal funds authoriZed for this funding period . . ., .' ... "0 "-.' i. Unobligated balance of Federal funds (Woe h minus line g) '" .., s. Type of Rate (Place -X- in appropriate box) 11. Indirect o Provisional o Prectetennned oFIII8I OFixecf Expense b.Rate Ie. Base /d. Total Amount e. Federal Share 12. RernarIcs: Attach any expJanationsdeerned necessary or infoIma1Ion required by Federal sponsoring agency in compliance with goveming legislation. 13. Certification: I certify to the best of my IlnowIecIge Md beliefthatthla repon Is c:onect and eompIete and that all outlays and unliquidated obligations are for the purpoMa At forth In the award documents. Typed or Printed Name and Title Telephone (Area code, number and extension) Signature of Authorized Certifying Official Date ReportSubmittecl ~D Standard Form 269A (REV 4-88) Prescribed by OMS Circulars A.102 and A-ttO