Form FEMA Form 20-17 FEMA Form 20-17 Outlay Report and Request for Reimbursement for Construc

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

PAGE

OUTLAY REPORT AND REQUEST FOR REIMBURSEMENT
FOR CONSTRUCTION PROGRAMS
3. FEDERAL SPONSORING AGENCY AND ORGANIZATIONAL ELEMENT TO
WHICH THIS REPORT IS SUBMITTED

6. EMPLOYER IDENTIFICATION
NUMBER

7. RECIPIENT ACCOUNT OR OTHER
IDENTIFYING NUMBER

OF

PAGES

1. TYPE OF REQUEST
FINAL

O.M.B. No. 1660-0025
Expires July 31, 2008
2. BASIS OF REQUEST

PARTIAL

CASH

4. FEDERAL GRANT OR OTHER
IDENTIFYING NO. ASSIGNED BY FEMA

ACCRUAL

5. PARTIAL PAYMENT REQUEST
NO.

8. PERIOD COVERED BY THIS REPORT
FROM (Month, day, year)

TO (Month, day, year)

9. NAME (Recipient Organization)

10. PAYEE (Where checks should be sent if different than item 9)

ADDRESS (City, State and Zip Code)

ADDRESS (City, State and Zip Code)

CLASSIFICATION
a. Administrative expense

11. STATUS OF FUNDS
PROGRAMS-FUNCTIONS-ACTIVITIES
(b)
(a)
$

TOTAL
$

$

b. Preliminary expense
c. Land, structures, right-of-way
d. Architectural engineering basic fees
e. Other architectural engineering fees
f. Project inspection fees
g. Land development
h. Relocation expense
i. Relocation payments to individuals and businesses
j. Demolition and removal
k. Construction and project improvement cost
l. Equipment
m. Miscellaneous cost
n. Total cumulative to date (sum of lines a thru m)
o. Deductions for program income
p. Net cumulative to date (line n minus line o)
q. Federal share to date
r. Rehabilitation grants (100% reimbursement)
s. Total Federal share (sum of lines q and r)
t. Federal payments previously requested
u. Amount requested for reimbursement
v. Percentage of physical completion of project
12. CERTIFICATION

a.
RECIPIENT

I certify that to the best of my knowledge and belief the
billed costs or disbursements are in accordance with the terms of
the project and that the reimbursement represents the Federal
share due which has not been previously requested and that an
b.
inspection has been performed and all work is in accordance with Representative
certifying to line
the terms of the award.
11 v.
FEMA Form 20-17, OCT 04

SIGNATURE
OFFICIAL

OF

AUTHORIZED

CERTIFYING

TYPED OR PRINTED NAME AND TITLE
SIGNATURE
OFFICIAL

OF

AUTHORIZED

TELEPHONE (Area code, number and
extension)
CERTIFYING

TYPED OR PRINTED NAME AND TITLE
OFFICIAL

PREVIOUS EDITION OBSOLETE

DATE REPORT SUBMITTED

DATE SIGNED
TELEPHONE (Area code, number and
extension)

Paperwork Burden Disclosure Notice
Public reporting burden for this form is estimated to average 17.2 hours per response. The burden estimate includes the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing, and
submitting this form. You may send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden
to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street,
SW, Washington, DC 20472. You are not required to respond to this collection of information unless a valid OMB control number appears
in the upper right corner of this form. NOTE: Do not send your completed form to this address.

INSTRUCTIONS
1.
2.
3.
4.

Mark the appropriate box.
Mark the appropriate box.
Enter the name of the FEMA Regional Office which awarded the grant/cooperative agreement to your organization.
Enter the number assigned by FEMA. This number can be found in item 1 of the Obligating Document for
Award/Amendment, FEMA Form 76-10A.
5.
This item will not be used to report in the EOC program.
6.
Enter the number assigned by the Internal Revenue Service. This number should be the same number reported in
item 6 of the applicant's Application for Federal Assistance, SF 424.
7.
This space is reserved for an account number or other identifying number assigned by the recipient.
8.
Enter the beginning and ending dates of the quarter you are reporting on.
9.
Enter the name and address of the organization receiving the grant. This information should be the same
information as shown in item 5 of FEMA Form 76-10A.
10.
Enter where checks should be sent if different than item 9.
11a.
Enter amount expended for such items as travel, legal fees, rental of vehicles and any other administrative
expenses. Include the amount of interest expense when authorized by program legislation.
11b.
Enter the amounts pertaining to the work of locating and designing, making surveys and maps, sinking test holes,
and all other work required prior to actual construction.
11c.
Enter all amounts directly associated with the acquisition of land, existing structures, and related
right-of-way (this includes purchase, lease, and/or easements).
11d.
Enter basic fees for services of architectural engineers relating to construction (this includes start-up services and
preparation of project performance work plan).
11e.
Enter amounts for other architectural engineering services, such as surveys, tests, soil borings, etc. Do not include
any amounts shown on line 11d.
11f.
Enter construction monitoring, engineering inspection, and audit fees of construction and related programs.
11g.
Enter all amounts associated with the development of land where the primary purpose of the grant is land
improvement.
11h.
Enter the dollar amounts used to provide relocation advisory assistance and net costs of replacement housing.
11i.
Enter the amount of relocation payments made by the recipient to displaced persons, farms, business concerns, and
nonprofit organizations
11j.
Enter gross salaries and wages of employees of the recipient and payments to third party contractors directly
engaged in performing demolition or removal of structures from developed land.
11k.
Enter those amounts associated with the actual construction of, addition to, or restoration of a facility. Also, include
the amounts for project improvements such as sewers, streets, landscaping and lighting.
11l.
Enter amounts for all equipment, both fixed and movable, exclusive of equipment used for construction.
11m.
Enter the amounts for all items not specifically mentioned above.
11n.
Enter the total cumulative amount to date which should be the sum of lines 11a through 11m.
11o.
Enter the total amount of program income applied to the grant or contract agreement except income on line j.
Identify on a separate sheet of paper the sources and types of the income.
11p.
Enter the net cumulative amount to date which should be the amount shown on line 11n minus the amount on
line11o.
11q.
Enter the Federal share of the amount shown on line 11p.
11r.
Enter the amount of rehabilitation grant payments made to individuals when program legislation provides 100 percent
payment by the Federal agency.
11s.
Enter the total amount of Federal share.
11t.
Enter the total amount of Federal payments previously requested, if this form is used for requesting reimbursement.
11u.
Enter the total amount being requested for reimbursement. This amount should be the difference between the
amounts shown on lines 11q and 11t. If different, explain on a separate sheet.
11v.
Enter the actual percentage of project already constructed.
12.
The purpose of this item is to verify that the costs or disbursements are in accordance with the terms of the project.
12a.
To be completed by the recipient official who is responsible for preparation and submission of the outlay report.
12b.
To be completed by the official representative who is certifying to the percent of project completion as provided for
in the terms of the grant or cooperative agreement. Refer to Outlays Module, Part III, for detailed instructions.