SF-271 Outlay Report and Request for Reimbursement for Construc

Page
1. TYPE OF REQUEST
FINAL

(See instructions on back)
3. FEDERAL SPONSORING AGENCY AND ORGANIZATIONAL ELEMENT TO WHICH THIS
REPORT IS SUBMITTED

6. EMPLOYER IDENTIFICATION
NUMBER

Pages
2. BASIS OF REQUEST
† CASH † ACCRUAL

PARTIAL

5. PARTIAL PAYMENT REQUEST NO.

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

7. RECIPIENT’S ACCOUNT NUMBER OR
IDENTIFYING NUMBER

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:

No. and Street:

No. and Street:

City, State and
ZIP Code:

City, State and
ZIP Code:

11.

Of

OMB APPROVAL NO. 0348-0002

OUTLAY REPORT AND REQUEST FOR REIMBURSEMENT
FOR CONSTRUCTION PROGRAMS

STATUS OF FUNDS
PROGRAMS
CLASSIFICATION

a. Administrative expense

FUNCTIONS

ACTIVITIES

(a)

(b)

(c)

$

$

$

$

$

$

$

$

TOTAL

b. Preliminary expense
c. Land, structures, right-of-way
d. Architectural engineering basic fees
e. Other architectural engineering fee
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
I certify that to the bet of my knowledge and belief the billed costs
or disbursements re 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 inspection has been
performed and ll work is in accordance with the terms of the award.

a. RECIPIENT

%

%

%

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

DATE REPORT SUBMITTED

TYPED OR PRINTED NAME AND TITLE

TELEPHONE (Area code, number)

SIGNATURE OF AUTHORIZED CERTIFYING OFFICIAL

DATE REPORT SUBMITTED

TYPED OR PRINTED NAME AND TITLE

TELEPHONE (Area code, number)

b. REPRESENTATIVE
CERTIFYING TO LINE 11v

AUTHORIZED FOR LOCAL REPRODUCTION
PREVIOUS EDITION USABLE
271-103

STANDARD FORM 271 (Rev. 7-2009)
Prescribed by OMB Circular A-102 and A-110

INSTRUCTIONS
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 (0348-0004), 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.
Please type or print legibly. Items 3, 4, 5, 8, 9, 10, 11s and 11v are self explanatory; specific instructions for other items are as follow:
Item

Entry
1

Mark the appropriate box. If the request is final, the amounts
billed should represent the final cost of the project.

2

Show whether amounts are computed on an accrued expenditure
or cash disbursement basis.

6

Enter the Employer Identification Number (EIN) assigned by the
U.S. Internal Revenue Service or 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.

11

The purpose of vertical columns (a) through (c) is to provide
space for separate cost breakdowns when a large project has
been planned and budgeted by program, function or 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. All amounts are reported on a cumulative basis.

Item

Entry

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. All proceeds
from the sale of salvage or the removal of structures should be credited
to this account; thereby reflecting net amounts if required by the
Federal agency.

11k

Enter those amounts associated with the actual construction of,
addition to, or restoration of a facility. Also, include in this category,
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. For example, permanently attached
laboratory tables, built-in audio visual systems, movable desks, chairs,
and laboratory equipment.

11m

Enter the amounts of all items not specifically mentioned above.

11n

Enter the total cumulative amount to date which should be the sum of
lines a through m.

11o

Enter the total amount of program income applied to the grant or
contract agreement except income included on line j. Identify on a
separate sheet of paper the sources and types of the income.

11p

Enter the new cumulative amount to date which should be the amount
shown on line n minus the amount on line o.

11q

Enter the Federal share of the amount shown on line p.

11r

Enter the amount of rehabilitation grant payments made to individuals
when program legislation provides 100 percent payment by the Federal
agency.

Enter basic fees for services of architectural engineers.

11t

Enter the total amount of Federal payments previously requested, if this
form is used for requesting reimbursement.

11e

Enter other architectural engineering services. Do not include
any amounts shown on line d.

11u

11f

Enter inspection and audit fees of construction and related
programs.

Enter the amount now being requested for reimbursement. This
amount should be the difference between the amounts shown on lines s
and t. If different, explain on a separate sheet.

12a

To be completed by the official recipient official who is responsible for
the operation of the program. The date should be the actual date the
form is submitted to the Federal agency.

12b

To be completed by the official representative who is certify to the
percent of project completion as provided for in the terms of the grant
or agreement.

11a

Enter amounts 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. Also show the amount of interest expense
on a separate sheet.

11b

Enter 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.

11d

11g

11h

11i

Enter all amounts associated with the development of land where
the primary purpose of the grant is land improvement. The
amount pertaining to land development normally associated with
major construction should be excluded from this category and
entered on line k.
Enter the dollar amounts used to provide relocation advisory
assistance and net costs of replacement housing (last resort). Do
not include amounts needed for relocation administrative
expenses; these amounts should be included in amounts shown
on line a.
Enter the amount of relocation payments made by the recipient
to displaced persons, farms, business concerns, and nonprofit
organizations.

Standard Form 271 (Rev. 7-2009) Back