SF-270 Request for Advance or Reimbursement

OMB APPROVAL NO.

PAGE

OF

0348-004

REQUEST FOR ADVANCE
OR REIMBURSEMENT

a. “X” one or both boxes
1.
TYPE OF
PAYMENT
REQUESTED

(See instructions on back)

PAGES
2. BASIS OF REQUEST

ADVANCE
CASH
REIMBURSEMENT
ACCRUAL
b. “X” the applicable box
FINAL

PARTIAL

3. FEDERAL SPONSORING AGENCY AND ORGANIZATIONAL ELEMENT TO
WHICH THIS REPORT IS SUBMITTED

4. FEDERAL GRANT OR OTHER
IDENTIFYING NUMBER ASSIGNED
BY FEDERAL AGENCY

6. EMPLOYER IDENTIFICATION
NUMBER

8.

7. RECIPIENT’S ACCOUNT
NUMBER OR IDENTIFYING
NUMBER

5. PARTIAL PAYMENT
REQUEST NUMBER FOR THIS
REQUEST.

PERIOD COVERED BY THIS REQUEST

From (month, day, year)

TO (month, day, year)

9. RECIPIENT ORGANIZATION

10. PAYEE (Where check is to be sent if different than item 9)

Name:

Name:

Number
and Street:

Number
and Street:

City, State
and ZIP Code:

City, State
and ZIP Code:

11.

COMPUTATION OF AMOUNT OF REIMBURSEMENTS/ADVANCES REQUESTED

PROGRAMS/FUNCTIONS/ACTIVITIES

(a)

(b)

(c)

a. Total program
Outlays to date

$

$

$

(As of date)

TOTAL
$

b. Less: Cumulative program income
c. Net program outlays (Line a minus line b)
d. Estimated net cash outlays for advance period
e. Total (Sum of lines c & d)
f. Non-Federal share of amount on line e
g. Federal share of amount on line e
h. Federal payments previously requested
i. Federal share now requested (Line g minus line
h)
j. Advances required
by month, when
requested by Federal
grantor agency for use
in making prescheduled
advances

1st month
2nd month
3rd month

12.

ALTERNATE COMPUTATION FOR ADVANCES ONLY

a. Estimated Federal cash outlays that will be made during period covered by the advance

$

b. Less: Estimated balance of Federal cash on hand as of beginning of advance period
c. Amount requested (Line a minus line b)
AUTHORIZED FOR LOCAL REPRODUCTION

$
(Continued on Reverse)

STANDARD FORM 270 (Rev. 7-2009
Prescribed by OMB Circulars A-102 and A-110

13.

CERTIFICATION

I certify that to the best of my knowledge and
belief the data on the reverse are correct and that
all outlays were made in accordance with the
grant conditions or other agreement and that
payment is due and has not been previously
requested.

SIGNATURE OR AUTHORIZED CERTIFYING
OFFICIAL

DATE REQUEST
SUBMITTED

TYPED OR PRINTED NAME AND TITLE

TELEPHONE (AREA CODE, NUMBER,
EXTENSION)

This space for agency use

Public reporting burden for this collection of information is estimated to average 60 minutes per
response, including time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send
comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the Office of Management and Budget, Paperwork
Reduction Project (0348-004), Washington, DC 20503
PLEASE DO NOT RETURN YOUR COMPLETED FORM TO THE OFFICE OF MANAGEMENT
AND BUDGET, SEND IT TO THE ADDRESS PROVIDED BY THE SPONSORING AGENCY.
INSTRUCTIONS
Please type or print legibly,. Items 1, 3, 5, 9, 10, 11e, 11f, 1g, 11i, 12 and 13 are self-explanatory: specific instructions
for other items are as follows:
Item

Entry

2

Indicate whether request is prepared on cash or accrued
expenditure basis. All requests for advances shall be prepared
on a cash basis.

4

Enter the Federal grant number, or other identifying number
assigned by the Federal sponsoring agency. If the advance or
reimbursement is for more than one grant or other agreement,
insert N/A; then, show the aggregate amounts. On a separate
sheet, list each grant or agreement number and the Federal
share of outlays made against the grant or agreement.

6

Enter the employer identification number assigned by the U.S.
Internal Revenue Service, or the FICE (institution) code if
requested by the Federal agency.

7

This space is reserved for an account number or other
identifying number that may be assigned by the recipient.

8

Enter the mon, day, and year for the beginning and ending of
the period covered in this request. If the request is for an
advance or for both an advance and reimbursement, show the
period that the advance will cover. If the request is for
reimbursement, show the period for which the reimbursement
is requested.

Note:

The Federal sponsoring agencies have the option of requiring
recipients to complete items 11 or 12, but not both. Item 12
should be used when only a minimum amount of information is
needed to make an advance and outlay information contained
in item 11 can be obtained in a timely manner from other
reports.

Item

Entry
activity. If additional columns are needed, use as many
additional forms as needed and indicate page number in space
provided in upper right; however, the summary totals of all
programs, functions, or activities should be shown in the “total”
column on the first page.

11a

Enter in “as of date,” the month, day, and year of the ending of
the accounting period to which this amount applies. Enter
program outlays to date (net of refunds, rebates, and discounts),
in the appropriate columns. For requests prepared on a cash
basis, outlays are the sum of actual cash disbursements for
goods and services, the amount of indirect expenses charged,
the value of in-kind contributions applied, and the amount of
cash advances and payments made to subcontractors and
subrecipients. For requests prepared on an accrued expenditure
basis, outlays are the sum of the actual cash disbursements, the
amount of indirect expenses incurred, and the new increase (or
decrease) in the amounts owed by the recipient for goods and
other property received and for services performed by
employees, contracts, subgrantees and other payees.

11b

Enter the cumulative cash income received to date, if requests
are prepared on a cash basis. For requests prepared on an
accrued expenditure basis, enter the cumulative income earned
to date. Under either basis, enter only the amount applicable to
program income that was required to be used for the project or
program by the terms of the grant or other agreement.

11d

Only when making requests for advance payment, enter the
total estimated amount of cash outlays that will be made during
the period covered by the advance.

11
The purpose of the vertical columns (a), (b), and (c) is to
provide space for separate cost breakdowns when a project has
been planned and budgeted by program, function, or

13

Complete the certification before submitting this request.

Standard Form 270 (Rev. 7-2009) Back